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4/77 • <br />MINED LAND RECLAMATIOPI <br />LIMITED I1iPACT AND SPECIAL 10-DAY PERMIT APPLICATION CHECKLIST <br />File No. - /7 Name ~ Ml~~,;a ~,M~(~. _ Date of Filing (Completeness) <br />IT.EPI COMPLETE ADEQUATE COMPfENTS <br />Application Form <br />1. Name of operation <br />/ <br />2. Name of applicant/operator f <br />3. Address 6 phone (local offices) <br />4. Address & phone (general offices) / <br />5. Person to contact / <br />6. Surface owners <br />/' ~ <br />7. 2~Liaeral owners / <br />8. Type of mine/substance ~ <br />9. General location S elevation ~ <br />10. County ~/ <br />11. Acreage ~/ <br />12. Fee /' <br />i3. Present land use /~ <br />14. Proposed future use / <br />15. Signature <br />Maps and Exhibits <br />1. Exhibit A - Legal description <br />~ <br />~j,1~ <br />2. Exhibit B - ~Sining plan ~/ <br />j3. Exhibit C - Map f <br />4. Exhibit D - Wi1d11f~Water Resoles, <br />7egetatib~and SoilsTnfor- <br />mation <br />~. Exhibit E - Reclamation plan / <br />