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• <br />~ iii iiiiiiiiiiiiiiii <br />999 <br />DIVISION OF MINERALS AND GEOLOGY <br />Limited Impact 110(2) <br />Application Worksheet/Checklist <br />New App: V Amendment App: Conversion App: <br />Operator: L} QL~y~~y Mine ID: 9~3QQ7 <br />Mine Name: 1i7eect~e~ Pc~-'~F- ~(Z_ Submittal Date: ( c~~p Q~ <br />APPLICATION FORM: <br />ITEMS 1 2 3 4 5 6 <br />COMPLETED <br />ITEMS 7 8 9 10 11 12 <br />COMPLETED <br />MAPS and EXHIBITS <br />ADEQUACY COMMENTS <br />EXHIBIT A - LEGAL DESCRIPTION & LOCATION MAP / <br />a~ . <br />EXHIBIT B - SITE DESCRIPTION <br />a. Vegetation & Soils /~ <br />0~. <br />b. Critical Structures within 200 feet and offsite <br />~~. <br />c. Water Resources and Wildlife Statement (if provided) <br />