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.+ ~+IrNruvar ;~ o. <br />10?9-0079 <br />U.S. DEPARTMENT OF THE INTERIOR <br />t . Ollice of Surface Mining <br />PROJECT APPROVAL INFORMATION <br />SECTION A <br />Item 1. <br />Does this assistance request require State, local, Name of Governing BodyMined Land Reclamation Bored <br />regional, or other priority rating? Priority Rating <br />X Yes No <br />Item 2 <br />Does this assistance request require Stafe, or local Name of Agency or <br />advisory, educational or health clearances? Board <br />Yes X No (Attach Documentation) <br />Item 3. <br />Does [his assistance request require clearinghouse (Attach Comments) <br />review in accordance with OMB Circular A-95? <br />X Yes No <br />Item a. <br />Does this assistanee request require State, local, Name of Approving Agency <br />regional or other planning epproval?~ Date <br />Yes X No <br />Item 5. <br />Is the proposed project covered by an approved Check one: State ^ <br />comprehensive plan? Local ^ <br />X Regional ^ <br />Yes No LocatlonofPlan Mined Land Reclamation Division <br />Item 6. <br />WIII the assistance requested serve a Federal Name of Federal Instatlatlon N/A <br />Installetlon? Federal Populallon beneflling from Project <br />Yes X No <br />Item 7. <br />WIII the assistance requested be on Federal land Name of Federal Irtstallatlon <br />or installetlon? Location of Federal Land <br />Yes X No Percent of Project <br />Item 8. <br />WIII the assistance requested have an impact or See instructions for additional information to be <br />effect on the environment? provided. <br />X Yes No <br />Item 9. Number of: <br />WIII the assistance requested cause the displacement Individuals <br />of Individuals, families, businesses, or [arms? Families _ <br />Businesses <br />Yes X No Farms _ <br />Item 10. <br />Is there other relatetl assistance on this project See instructions for additional information to be <br />previous, pending, or anticipated? X provided. <br />Yes No <br />Item 11. <br />Is the project in a designated flood hazard area? <br />Yes X No <br />See instructions for additional information to be <br />provided. <br />OSM-50A (6180) <br />