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,- <br />Limited Impact (110) <br />Special 10-Day (111) <br />ITEM <br />~~ <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />• ~I I I II I I~ I I~ II~~ II~ <br />sss <br /> <br />Fnc~+' l~ 1 <br />Name I~vnn.noGrzk 1.,~~ : File No./l7-55~003 <br />Complete filed Date <br />COMPLETE ADEQUATE (COMMENTS <br />Application Form: <br />1. Name of Operation <br />/ <br />/ <br />2. Name of Applicant/Operator \/ / <br />3. Address & Phone (Local) / / <br />4. Address & Phone (General) / / <br />5. Person to Contact / / <br />6. Surface Owners / / <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 />/ ~ ~.E °~d`~° `~;"`" <br />a ii <br />i.~~~ ~ <br />16. Signature / / <br /> <br />