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1 '' • • <br />III IIIIIIIIIIIII III <br />DIVISION .,. .._..~99 ., .~...~ GEOLOGY <br />Limited Impact 110(2) <br />Application Worksheet/Checklist <br />New App: ~ Amendment App: Conversion App: <br />Operator: ~~ Mine ID: /-/~ - Q`{ -001 <br />Mine Name: ~-o hso,,~ (~;-}- Submittal Date:rp~ °~ ~q~y <br />APPLICATION FORM: <br />ITEMS 1 2 3 4 <br />lq-l 5 6 <br />COMPLETED y <br /> -PEe ~o f <br />ubm%HPCQ <br />~ <br />~ <br />ITEMS 7 8 9 10 11 12 <br />COMPLETED <br /> 1 / <br />V <br />/ ' / <br />V / <br />V ~~ 1 <br />~I 'F Q ~/ <br />\ ~'Xi 5 Icy <br />J <br />\ <br /> 1~4Q No'f CQ~ 1 C~\ <br />~ <br />MAPS and EXHIBITS ADEQUACY COMMENTS <br />EXHIBIT A - LEGAL DESCRIPTION & LOCATION MAP CSInowS 1 pia ~X ~ <br />©I< oK <br />EXHIBIT B - SITE DESCRIPTION <br />a. Vegetation & Soils <br />b. Critical Structures within 200 feet and offsite damage <br />ok <br />c. Water Resources and Wildlife Statement (if provided) <br />p k-. ~K <br />