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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: <br />Operator: ~~~,y-~ ~~~~~ <br />Mine Name: ~~p-~m~, L~j.{,~ <br />Conversion App: // <br />Mine ID: _ (~a-~~T <br />Submittal Date: 7~~'~Y3 <br />APPLICATION FORM: <br />- V ©' <br />ITEMS <br />COMPLETED 1 2 3 4 5 6 <br /> d J <br />ITEMS <br />COMPLETED 7 8 9 10 11 12 <br /> / ,/ <br />MAPS and EXHIBITS <br />ADEQUACY COMMENTS <br />EXHIBIT A - LEGAL DESCRIPTION & LOCATION MAP N <br />EXHIBIT B - SITE DESCRIPTION <br />a. Vegetation & Soils <br />b. Critical Structures within 200 feet and offsite damage <br />c. Water Resources and Wildlife Statement (if provided) ~~ <br />