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~/~a / <br />LIMITED IMPACT (110) ~! • <br />SPECIAL 10-DAY (111) _ III <br />ITEM <br />APPLICATION CHECKLIST <br />c~~ - <br />NAME hn~<`/~%~~''-'7 - /!~U! T F I LE ~`~ <br />IIIIIIIIIIIIIIII MPLETE-(FILED)-DATE---S_~_ ~O_---_---- <br />999 _ MPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation -~~- <br /> <br />2. Name of applicant/operator 1 <br />3. Address 6 phone, local I <br />l <br />4. Address ~ phone, general / <br />5. Person to contact ~ l <br />/ <br />6. Surface owners / <br />r <br /> <br />7. Mineral owners I \ <br />\ <br />1 <br />8. Source of legal right-to-enter \ <br />l <br />9. Type of mine/substance \ <br />10. General location r; elevation ~ <br />11. County <br />J <br />( <br />12. Acreage \ <br />13• Fee <br />14. Present land use <br />I <br />15. Proposed future use / <br />16. Signature <br />Maps and Exhibits <br /> <br />EXHIBIT A - Leval Description <br /> <br />._.'," <br />A <br />EXHIBIT B - Mining Plan <br />EXHIBIT C - Map <br />,~ <br />EXH IBIT D - Wi Idl i fe', G~'a3er Resources, <br />Vegetation., ~Soi Is Informatiori~ ,i~ <br />L <br />