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• • III IIIIIIIIIIIII III <br />999 <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />Limited Impact (110) Name D°lo Ins G,- rer A. <br />•f `~ File No. -8-~r_lSS <br />Special 10-Day (111) Complete Fi ed Date Sao f, 5`i 19~~ <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br /> ~ X <br />2. Name of Applicant/Operator <br /> X ~ <br />3. Address & Phone {Local) <br /> ~ ~ <br />4. Address & Phone {General) <br /> n x <br />5. Person to Contact ~ <br /> <br />6. Surface Owners <br /> ~ x <br />7. Mineral Owners <br />8. Source of Legal Right-To-Enter <br /> x X <br />9. Type of Mine/Substance <br /> ~ ~ <br />10. General Location & Elevation X <br /> x <br />11. County <br /> X <br />12. Acreage <br />x <br />13. Fee `/ <br />/` <br />~ <br />14. Present Land Use <br />15. Proposed Future Use <br />16. Signature `~ X <br />