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]/78 APPLICATION CHECKLIST ~il ~~ <br />LIMITED IMPACT (ll0) _~ NAME ~~~~'-"~ ~.-~-~ FILE N8~-r; <br />SPECIAL 10-DAY (111) _ COMPLETE (FILED) DATE a , i 9~0 <br />------------------------------------------------------------------- --- -T-------------- <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />2. Name of applicant/operator ~~ <br />3. Address & phone, local <br />~- <br />4. Address E phone, general r <br />5. Person to contact l <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 E elevation <br />11. County <br />12. Acreage <br />13. Fee <br />14. Present land use <br />15. Proposed future use <br />16. Signature <br />Maps and Exhibits <br />EXHIBIT A - Legal Description <br />EXHIBIT B - Mining Plan / <br />EXHIBIT C - Map L~ <br />EXH IBIT D - Wildlife, Water Resources, <br />Vegetation, Soils Information r' / <br />V <br />