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• ~ • iii iiiiiiiiiiiu iii <br />999 <br />MINED LAND RECLAMATION <br />A lication Worksheet/Checklist <br />~~ %u~ioe~ C-0. <br />Limited Impact (110) Name e Greed cFr File No.M-86-/Oz <br />Special 10-Day (111) Complete filed Date g - ~ - ~(~ <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br />~ <br />l~ <br />2. Name of Applicant/Operator (~ d/ <br />3. Address & Phone (Local) / <br />1/ a~ <br />4. Address & Phone (General) / / <br />l <br />/ <br />5. Person to Contact ~ / <br />(/ <br />6. Surface Owners ~ <br />7. Mineral Owners ~(~ <br />8. Source of Legal Right-To-Enter <br />9. Type of Mine/Substance ~ <br />/ <br />/ <br />10. General Location & Elevation ~ <br />11. County ~ / <br />( <br />/ <br />12. Acreage ~ / <br />13. Fee_ <br />14. Present Land Use <br /> <br />15. Proposed Future Use <br />// <br />V S etl~ assµ. <br />Wi~~~/~,` / r`(~ <br />~-b <br />16. Signature / <br />~. ~~ <br />