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999 <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />i~ act. 11 Name ~,~a~l~c,v,N„u. File No.m ~')_QQa <br />pedal 10-Da~~ (111) Complete Filed Date S lR'-8 ~ <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Farm: <br /> X <br />1. Name of Operation - <br />2. Name of Applicant/Operator X X <br />3. Address & Phone (Local) ~ X <br />4. Address & Phone (General) <br />~~ <br /> <br />5. Person t.o Contact ~/ <br />/ X <br />6. Surface Owners ~ <br />7. Mineral Owners <br /> <br />8. Source cf Legal Right-To-Enter ~ t <br />9. Type of Mine/Substance <br /> 1 1 <br />10. General Location & Elevation X X <br />11. County <br /> <br />12. Acreage ~ ~ <br />13. Fee. \/ <br />14. Present Land Use ~ X <br />15. Proposed Future Use X <br />16. Signature ~ \/ <br />