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New App: <br />Operator: <br />Mine Name: ~~11 <br />APPLICATION FORM: <br />t III IIIIIIIIIIIII III • I~ <br />999 <br />DIVISION OF MINERALS AND GEOLOGY <br />Limited Impact 110(2) ~ <br />Application WorksheetJChecklist <br />Amendmen^^t--App: ~ Conversion App: <br />~/~+~[~ ~~N l_.C.) Mine ID: ~ ~] - Qoa H/Z <br />'_('V l.Q~31RJJ_ Submittal Date: ~~aJlp/Q ~j <br />~- i'j1- OD l <br />ITEMS 1 2 3 4 5 6 <br />COMPLETED <br />ITEMS 7 B 9 10 11 12 <br />COMPLETED <br />MAPS and EXHIBITS ADEQUACY COMMENTS <br />EXHIBIT A - LEGAL DESCRIPTION & LOCATION MAP ~/ <br />EXHIBIT B - SITE DESCRIPTION <br />a. Vegetation & Soils / <br />b. Critical Structures within 200 feet and off site damage <br />c. Water Resources and Wildlife Statement (if provided)'~~ <br />