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~/]$ APPLICATION CNELiCLIST <br />LIMITED IMPACT (110) ~ •~~ <br />~-2 rF~~S~~l <br />SPECIAL 10-DAY (111) _ <br />---------------------------------------- <br />ITEM <br />NAME ~O"_'^ Cu-~'JY.i <br />COMPLETE (FILED) DATE ~ <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />v' <br />2. Name of applicant/operator ~~ <br />3. Address E phone, local / <br />4. Address E phone, general Li <br />5. Person to contact ,~ <br />b. Surface owners L, <br />7. Mineral owners ~~ <br />8. Source of legal right-to-enter rim <br />9• Type of mine/substance ~~ <br />10. General location E elevation vi e~c~ w, a•..~ <br />11. County /. <br />12. Acreage <br />13. Fee ~ <br />14. Present land use /~ <br />15• Proposed future use r/ <br />16. Signature !/~ <br />Maps and Exhibits <br />EXHIBIT A - Legal Description <br />`/~ _._., <br />EXHIBtT B - Mining Plan ~~ <br />EXHIBIT C - Map ~~ <br />EXH IBIT 0 - Wildlife, Water Resources, <br />Vegetation, Soils Information ~~r~~~~--..1 <br />J <br />FJLE a ~ <br />