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<br /> <br />DIVISION OF MINERALS AND GEOLOGY <br />Limited Impact 110(2) <br />Application Worksheet/Checklist <br />~~' y ` <br />New App: / Amendment App: Conversion/ App: <br />Operator: e. d Mine ID: y - a <br />Mine Name: T_1-b/~ ~•~ ~d c rf~ Submittal Date: <br />APPLICATION FORM: <br />ITEMS 1 2 3 4 5 6 <br />COMPLETED <br />ITEMS <br />COMPLETED 7 8 9 <br /> <br />.... <br />L 10 11 12 <br /> CCH'Yli'~ <br /> <br />~~~'" ~oiG~ <br />vfG; ( <br />Gl~lt~.l,1~ ~ <br /> <br />. /J'~ <br />~( <br />_'` ~' <br />/ d'v~,va~ R~vt~ u.~ot~s ~ <br />MAPS and EXHIBITS ADEQUACY COMMENTS <br />SENui 3Z- ,~,/ ~9u0ct,. <br />EXHIBIT A - LEGAL DHSCRIPTION & LOCATION MAP <br />EXHIBIT B - SITE DESCRIPTION -~~ <br />a. Vegetation & Soils <br />~~ <br />~~- ~- - . <br />[; LG~n. Viz f'~v ~vbc(.i ~. ~wy1c~{'Ja) / / ,I, `~ <br />N,t 90-033 Q c ~ ~1 (~t~~ ~f- ~ <br />(700 /Goo.. CSGS ,~por~s) <br />b. Crritical Structures within 200 feet and offsite damage!/ <br />c. Water Resources and Wildlife Statem nt ~(if provided) <br />u~a ~~~ ak . ~~~,~ <br />