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4/771 _ <br />III IIIIIIIIIIIII III <br />" LIMITED L*I <br />File Na, urG7 Name S4 <br />-~ <br />Mll`iED LeV~ID RECLAMATIOLt <br />Date of Filing (Completene:as): <br />ITFn•*_ COiSPLETL ADEQUATE COiP1ETTS <br />Application Form <br />1. Name of operation <br />A~~ ~N ~ ~ <br />2. Name of applicant/operator <br />3. Address ~ phone (local offices) <br />4. Address S phone (general offices) <br />5. Person to con[act /, <br />1~ <br />5. Surface owners j I <br />7. Piineral owners / <br />8. Type of mine/substance <br />9. General location ~ elevation 1 <br />i <br />I0. County I <br />ll. Acreage <br />I2. c'ee ,y r I <br />13. Present land use I ~r ` <br />14. Proposed future use <br />r ~ <br />i <br />' <br />15. Signature ~/ <br />Naps and Exhibits <br />1. Exhibit A - Legal description <br />,~ <br />~. Exhibit S - ?~iaing plan <br />NI <br /> <br />3. Exhibit C - .Sap <br />Nt~ ~ // <br />~L;rv a.~.t <br />~ <br />4. Exhibit D - Wildlife`,~Wacer Resource, <br />7egetatio~nd Soiis ~i.afor- <br />motion <br />~ <br />S. Exhibit B - ?eclamation plan ~ _ <br />v <br />