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/7' <br />`LIED LA?iD ?tECLAri4TI0iI <br />LL*SITED L`D?ACT ?.i1D SF°CL4L 10-DAY PYEi?IT APPLIiaTIO:~T C°..EC:C;IST <br />File `io. ~a'-3-o Vame L~~o~~. C~ Date of Fi1L^g (Completeness) <br />I'?'E:"_ COig'LETE ! ADEQIIATE COyiDITS <br />Application Fors <br />1. Yame of operation <br />i <br />2. name of applicant/operator <br />3. Address S phone (local offices? <br />I <br />~ <br />~ <br />4. Address & phone (general offices) <br />.i. Person to contact <br />5. Sur`_ace ou*ners ` <br />i <br />7. ?iiaeral o•.~mers l <br />S. T;*pe of mi.ae/substance <br />9. General Location S elevation f <br />f <br />- ~ <br />Z0. County <br />i <br />il. Ycreage <br /> <br />I.. Fee i <br />~ ~ <br />l3. ?reserc land use ~ <br />1 _ <br />~ <br />l4. ?roposed future use + l~ <br />I l ~ <br />L . Signature <br />:"ans and E.~ch'~-its <br />1. cshibit A - Legal destript_oa <br /> <br />Z. Es.`:ibit S - .4iaiag plan i <br />3. =zhi3it C - yap I + ~ <br />I <br />4. Exhibit D - 'diidlife, Slater Fesources, <br />7egetatioa and Sails i~.fcr- <br />oration / <br />G/ <br /> <br />I <br />S. F4hibit - ?eclamation plan <br />