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._ <br /> <br />~II I <br /> <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />Limited Impact (110) Name P ~ :~W ~kc, P;f u„t1" <br />Special 10-Day (111) Complete Filed Date ~II~IIIII~~II~ <br />sss <br /> <br /> <br />File No.M-B~-/'r <br />q y <br /> <br /> ITEM COMPLETE ADEQUATE COMMENTS <br />App <br />1. lication Form: <br />Name of Operation <br />2. Name of Applicant/Operator <br />3. Address & Phone (Local) <br />4. Address & Phone (General) <br />5. Person to Contact <br />6. Surface Owners <br />7. Mineral Owners <br />8. Source of Legal Right-To-Enter <br />9. Type of Mine/Substance <br />10. General Location & Elevation <br />11. County <br />12. Acreage <br />13. Fee <br />14. Present Land Use <br />15. Proposed Future Use <br />16. Signature <br />