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III III~IIIII~~~I111 APPLICATION CHECKLIST ' <br />r ~l~nli1i t1u IMPACT (110) ~ • NAME Cu~i`o a c ,~~G~ ~Y~<<< % f FILE N~1Ti~ <br />SPECIAL 10-DAY (111) _ COMPLETE (FILED) DATE i <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation C'/L <br />2. Name of applicant/operator <br /> Q /~ <br />3. Address b phone, local <br /> G /C <br />4. Address b phone, general <br /> D ~C <br />5. Person to contact <br />~lC <br />6. Surface owners <br /> G~ <br />7. Mineral owners ~ <br /> G/~ <br />8. Source of legal right-to-enter G~C <br />9. Type of mine/substance G/C <br />10. General location & elevation <br /> G /C <br />11. County <br />~/C <br />12. Acreage ~~ <br />13• Fee p` <br />/~/ <br />14. Present land use G~~ <br />15. Proposed future use <br /> d / <br />16. Signature <br />~/C <br />Maos and Exhibits ~' ~~ r ~, s' <br /> f~< <br />EXHIBIT A - Legal Description "~ ~ ~~~` "~~ <br />~` <br /> L;~ <br /> <br />EXHIBIT B - Mining Plan ~~ ~ <br /> <br /> <br />EXH I B I T C - Map /~ [. <br />C~/~ <br /> <br />EXH IBIT D - Wildlife, Water Resources, <br /> <br />~~ qqt .. <br />0 <br />~ ~ <br />` a.et e. r ~. ~. ~ n ~- <br /> <br />''~~~~ <br />Vegetation, Soils Information L' <br />