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wl7t .. <br /> <br /> <br />?~'fED L?u~iD ?ZECLA2~.ATIOiI <br />~IPACT AND SPECIAL 10-DAY PERiaTT APPLICATION C'dEC~IST <br />77-Iy ~O.SnY Ce-.~L <br />File Vo. C Vane ~fi~I_ ~. Date of Filing (Completeness): <br />L'*~ CO~LETE I ADEQIIATE COMP~ZTS <br />implication Form <br />1. Name of operation <br />2. Name of apalicaat/operator ~ / <br />3. Address ~ phone (local offices) / <br />4. Address 5 phone (general offices) I ~ <br />~. Person to contact -~ <br />E. Surface oc~aers ~ 1 <br />i <br />7. :iiaeral owners. ~ <br />5. Type of amine/substance ~ ~ <br />9.. General location S elevation ~ <br />L0. Count7 <br />I <br />L1. acreage I - ~ - <br />Il. Fee <br />i.3. ?resent land use I -- I I <br />L+. ?ronosed future use <br />IS. Signature --~ <br />Maps and c.~chibits <br />1. 'sxisibit A - Legal description <br />~ <br />Z. Exiibit 3 - Eitning elan ~- <br />3. F.:chibit C - .'ao ~- <br />- <br />4. ~ibit 0 - 'dildlife, Water 3esources, <br />7egetation and Sails iasor- <br />matior. <br />`~ ~ i <br />5. SY'~ibit - 3eciaracion elan ` ~ <br />