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4/77T • • III III III IIIIIIIIII <br />MINED LAi~ID RECLAPtATION <br />LIMITED 7SIPACT AND SPEC-InAL 10-DAY PERMIT APPLICATION CHECKLIST <br />~il.e No, Name SUMM.~~ 'Q+'cX>es~ $rcC~c Date of Filing (Completeness) <br />ITEM COMPLETE ADEQUATE COMPSEiTS <br />Application Form <br />1. Name of op\ ation <br />/ <br />l <br />2. Name of applicant/operator <br />~/ <br />3. Address 6 phone (local offices) ~ <br />4. Address 6 phone (general offices) ~ <br />5. Person to contact ~ <br />6. Surface o~mers <br />7. Pfineral owners / <br />8. Type of mine/substance f <br />9. General location 6 elevation <br />10. county <br />11. Acreage / ~ 9 <br />12. Fee <br />13. Present land use ~/ <br />14. Proposed future use f <br />15. Signature ~ <br />Maps and Exhibits <br />1. Exhibit A - Legal description / <br />~/ <br />~N <br />2. Exhibit Ii - .fining plan ~/' <br />3. Exhibit C - Map <br />4. Exhibit D - Wildlife dater Resour es, <br />VegetatioxYand Soil infor- <br />mation <br />3. Exhibit E - Reclamation plan ~ d <br /> <br />