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~ III IIIIIIIilllll III <br />999 <br />• <br />MINED LAND RECLAMATION <br />lication Worksheet/Checklist <br />Limited Impact (110) <br />Special 10-Day (111) <br />ITEM <br />V ~~ ~ '~ ~ ~ <br />Name . , r~ .. t~~,. P `.'. <br />Complete Filed Date <br />File No. -~6-~`~ <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br />x <br />~( <br />/ <br />\ <br />2. Name of Applicant/Operator ~ ~ <br />3. Address & Phone (Local) ~ x <br />4. Address & Phone (General) V <br />5. Person to Contact <br />6. Surface Owners <br />7. Mineral Owners <br />8. Source of Legal Right-To-Enter ~/ <br />! <br />~ <br />9. Type of Mine/Substance ~ <br />10. General Location & Elevation <br />11. County y~ <br />12. Acreage x <br />13. Fee. •.~ <br />14. Present Land Use <br />15. Proposed Future Use <br />16. Signature ~' f-l`'~ <br />7 <br />-, f <br />