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]/]$ APPLICATION CHECKLIST <br />7e~- <br />LIMITED IMPACT (110) ~ NAME 5/G,~!/9L~.=,9K./ZitN~/%~ CO. FILE 11Zfr <br />SPECIAL 10-DAY (111) _ COMPLETE (FILED) DATE ~- ~~ ` 7j~' <br />---------------------------------------------------------------------------------------------- <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br /> <br />1. Name of operation <br />2. Name of applicant/operator f <br />3. Address E phone, local ,l I <br />4. Address b phone, general <br /> <br />5. Person to contact ~ <br />6. Surface owners <br />7. Mineral owners <br />' <br />8. Source of legal right-to-enter <br />9• Type of mine/substance I <br />10. General location ~ elevation , <br /> ~ <br />ll. County <br />12. Acreage G <br />13• Fee <br />(/ <br />~S ~ ~ ~~ <br />14. Present land use <br /> I <br />15• Proposed future use , <br />16. Signature <br />Maps and Exhibits <br /> ~ <br />EXHIBIT A - Legal Description <br /> i; -. , <br />EXHIBIT 8 - Mining Plan / <br />(/ <br />EXHIBIT C - Map (/~ <br /> <br />EXH IBIT D - Wildlife, Water Resources, f _ <br />Vegetation, Soils Information c~ " , <br />