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,, • • <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />Limited Impact (110) Name p,a,~ Os~twuflpd 1->c File No.M-fib-I~pQ <br />Special 10-Day (111) Complete Filed Date <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br />X <br />k <br />I <br />2. Name of Applicant/Operator Y <br />3. Address & Phone (Local) X <br />4. Address & Phone (General) x <br />5. Person to Contact y <br />6. Surface Owners X <br />7. Mineral Owners ~( <br /> <br />8. Source of Legal Right-To-Enter <br />~ <br />r~ ~FJ ie..~] of a pn rw <br />~,~;t.n~ ~N,nc~ <br />wayen,.~ n <br />9. Type of Mine/Substance x k <br />10. General Location & Elevation Y <br />/\ X <br />11. County k <br />12. Acreage ~ X1 <br />13. Fee. <br />14. Present Land Use ,, <br />15. Proposed Future Use ~0 <br />16. Signature <br /> <br />