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- ~ • iii iiiiiiiiiiiuiii • <br />999 <br />i4INED LAND RECLAMATION <br />Application Worksheet/Checklist <br />C-[CK/e r. /n G . ~i <br />I imitori Tmn art /71(11 Nomo 2_ ~G'. ./ /71 Gale Ni. or ~ i/ <br />_..... ___ _._~_ ~.._~ <br />Special 10-Jay (111) .._...- .. a.. .. ~ <br />Complete Filed) Date '~} .... ..,.. ~...-..-. <br />s, ~~~;~ <br /> <br /> ITEP1 COMPLETE ADEQUATE COMMENTS <br />App <br />1. lication Fonn: <br />Name of Operation <br />2. Name of Applicant/Operator <br />3. Nddress & Phone (Local) i/ <br />4. Address & Phone (General) / <br />5. Person to Contact ~/ <br />b. Surface Owners ~ <br />7. Mineral Owners ~ <br />d. Source of Legal Right-To-Enter ~ <br />U. Type of Mine/Substance ~/ <br />lO. General Location & Elevation ~ <br />11. County ~ <br />1Z. Acreage ~/ <br />13. Fee / <br />14. Present Land Use ,/ <br />15. Proposed Future Use ~ <br />16. Signature <br />