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<br />Limited Impact (110) <br />Special 10-Day (111) <br />• ~II II~~I~~I~~~~~ ~II <br />999 <br />MINED LAND RECLAMP,TIUN <br />Application Worksheet/ChecRlist <br />Pr:dewJrQ wwrf ,.,c r'aw~ ln~. <br />Name "Tessa Lea a v,..r.u..'~ Fide No.M-~`r-o43 <br />Complete Filed) Date ~,_/~ /9~~ <br />ITEh1 <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br /> x <br />2, Name of Applicant/Operator <br /> X <br />3. Address & Phone (Local) <br /> ~ n <br />4, Address & Phone (General) <br /> J'- x <br />5, Person to Contact <br /> x <br />d, Surface Owners <br />7, Mineral Owners <br />8, Source of Leyal Right-To-Enter <br /> x <br />y, Type of Mine/Substance <br /> <br />lU. General Location & Elevation <br /> ~ ~ <br />11. County <br /> X <br />12. Acreage <br /> ~ ~ <br />13. Fee <br /> x <br />14. Present Land llse <br /> r~ x <br />15. Proposed suture Use <br /> <br />16. Signature <br /> ,~ X <br />