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• • iii ii~iiiiiiiiu iii <br />999 <br /> <br />DIVISION OF MINERALS AND GEOLOGY <br />Limited Impact 110(2) <br />Application Worksheet/Checklist <br />New App: / Amendment App: Conversion App: <br />Operator: Ci / Mine ID: -~ <br />Mine Name: J P;~f Submittal Date: c4 <br />APPLICATION FORM: <br />ITEMS 1 2 3 4 5 6 <br />COMPLETED <br /> ~,,~.- <br /> <br />ITEMS <br />COMPLETED 7 8 9 10 11 12 <br />P1e,(r~~~~Y <br /> Tc~~ <br />,n <br />MAPS and EXHIBITS <br />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 offsite damage <br />c. Water Resources and Wildlife Statement (if provided) / <br />