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. ~".~ <br />Limited Impact (170) <br />Special 10-Ddy (111 ) <br />Application -Fonn: <br />MINED III III'IIIIIII~IIII _ <br />Application Worksheet/Cnecklist / <br />operator /) ~ ~ (w,,,,~flo ~.~,w~ <br />Mine Name Ir , ~ i ie No. ~- - y <br />Complete (i a ate <br />ITETts <br />Complete: I I 1 <br />I L 2 <br />v 3 <br />~ 4 5 <br />,_ I 6- 7 <br />_ <br /> <br />I7F1ds <br />Com lete: I 8 <br />/ I 9 <br />1 ~ 10 11 ~ 12 I <br />•- l3~ <br /> <br />COMPLETENESS/ADEQUACY COMMENTS <br />Maps and Exhibits: <br />EXHIBI7 A - Legal Description v <br />EXHIBIT B - Site Description <br />a Vegetation 8 Soils r/ <br />b. Wildlife <br />c. Griiical Structures <br />within 200 feet N ~~ <br />off-site damage <br />EXHIBIT C - Mining Plan <br />~- <br />EXHIBIT D - Re~elamation Plan <br />a. Plan <br />,./ <br />