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• III IIIIIIIIIIIII III` • <br />999 <br />MINED LAND RECLAMATION <br />A lication 'dorksheet/Checklist <br />Limited Impact (110) Name / ~~.f'n .o~_ ~:~ ,.,o.sFile No. M_Ry ro3 <br />Special 10-0ay (111) Comple a filed) Date ~.1,...,... ~,,,/9~Y <br />ITEht COh1PLETE ADEQUATE COMMENTS <br />Application Forin: <br />1. iVame of Operation ~ v <br />2. Name of Applicant/Operator ~ <br /> v <br />3. Address & Phone (Local) <br /> v / <br />4. Address & Piione (General) <br /> ~ <br />5. Person to Contact <br /> ~ <br />L~ <br />6. Surface Owners v <br /> L <br />7. Mineral Owners ,/ ~ <br />d. Source of Legal Right-To-Enter v :.~ <br />~. Type of Mine/Substance <br /> <br />lU. General Location & Elevation <br /> ~ <br />11. County v ~ <br />12. Acreage ,/ <br /> ~ <br />13. Fee N~ ,, <br />l~l. Present Land Use ~ <br /> <br />15. Proposed Future Use ~ V <br />lo. Signature ~ ~ <br />