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~ III IIIIIIIIIIIII III <br />• <br />DIVISION OF MINERALS AND GEOLOGY <br />CONSTRUCTION MATERIALS <br />Limited Impact 110 Mining Operation <br />Application Worksheet/Checklist <br /> <br />New App:~_. Amendment App: Conversion App: <br />Operator: {~cl~,~i,'r~lQ 1 Mine ID: ()')~~Op~J~ <br />Mine Name: ~~(,l~e ~r~~/P,~ Submittal Date: o/ / °l9 <br />APPLICATION FORM (Rule 1.6.2 and 1.6.3): <br />ITEMS <br />COMPLETED 1 2 3 4 5 6 <br /> / V ~ / / / <br />ITEMS 7 8 9 10 11 12 <br />COMPLETED <br /> c/ / ~ ,/ '~ <br />ITEMS CONV/AMEND PERMITEE SIG <br />COMPLETED DESCP RESP <br /> Y 2/ 3~ <br /> 4/~ 6'~ '~ <br /> .U 8/ 9~ <br />MAPS and EXHIBITS (Rule 6.2 & 6.3) <br />ADEQUACY COMMENTS <br />EXHIBIT A - 6.3.1 - LEGAL DESCRIPTION & LOCATION MAP,/,/ <br />