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__ _.. <br />~, <br />~II I~~I~I!II"II I~I <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />Limited Impact (110) Name <br />Special 10-Day (lll) Complete Filed Date <br /> <br /> <br />ile No. <br /> <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br />~ <br />,~ <br />2. Name of Applicant{Operator L ~ <br />3. Address & Phone (Local) L <br />4. Address & Phone (General) it ~ <br />5. Person to Contact .. <br />6. Surface Owners v <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 /> <br />