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<br />• <br /> <br />DIVISION OF MINERALS AND GEOLOGY <br />Limited Impact 110(2) <br />/ Application Worksheet/Checklist <br />New App: / Amendment App: Conversion'/App: <br />Operator: ~rkiw Po~.('i~ rmPpCOr~ Mine ID: Q~t-~$~ <br />Mine Name: 8P_e' 8rp~ o~.w.9e~ Submittal Date: '7/0?(~~ <br />APPLICATION FORM:~~~ ~~~~~ - ~Ci~ ~/~.I ~Y <br />ITEMS 7 8 9 10 11 12 <br />COMPLETED <br />MAPS and EXHIBITS ADEQUACY CONA9ENTS <br />EXHIBIT A - LEGAL DESCRIPTION & LOCATION MAP // <br />EXHIBIT B - SITE DESCRIPTION <br />a. Vegetation & Soils ~/ <br />b. Critical Structures within 200 feet and offsite damage ~1-._,~~~~~~~ <br />c. Water Resources and Wildlife Statement (if provided)~~~{ U <br />bh'~C~ ~Cl~?''-L'~~. IZ.t.e- w4.~L I~c'~,. -1~-~ ~~,~~Q 1 <br />