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_.J ~ • . • IIIIII'll'IIIIII'11 <br />DIVISION OF MINERALS AND GEOLOGY <br />Limited Impact 110(2) <br />Application Worksheet/Checklist <br />New Application: 2_~ Amendment Application: <br />Operator: RnnJC'_Y' .~~kalr.~m ~GnM(~1 tnrtc7 Mine ID: ~ - ~ ©Q <br />Mine Name : F°~ ~ l)C%~ I~~~1 r i`~- Submittal Date : t 0 (~ ~Qa <br />APPLICATION FORM: <br />ITEMS <br />COMPLETED 1 2 3 4 5 6 <br /> ,j / <br />ITEMS <br />COMPLETED 7 8 <br />~'~"-'' ~ 9 10 11 12 <br /> <br />f <br />~ / <br />/ <br />MAPS and EXHIBITS <br />ADEQUACY COMMENTS <br />EXHIBIT A - LEGAL DESCRIPTION & LOCATION MAP /~ <br />EXHIBIT B - SITE DESCRIPTION <br />a. vegetation & Soils <br />b. Critical Structures within 200 feet and offsite damage / <br />c. Water Resources and Wildlife Statement (if provided)/ <br />