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7/78 APPLICATION CHECKL I ST III IIIIIIIIIIIII III <br />sss <br />LIMITED IMPACT (110 _ ~ NAME Y~v CIA, LNG FILE ~/78-e77/ <br />SPECIAL 10-D 11) _ COMPLETE (FILED) DATE //r7S~ <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />2. Name of applicant/operator / <br />/ <br />3. Address b phone, local ~ <br />4. Address b phone, general <br />5. Person to contact <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 b elevation <br />11. County <br />.~ <br />12. Acreage <br />9~ <br />13. Fee ~ <br />14. Present land use / <br />15• Proposed future use J <br />16. Signature / <br />V <br />Maps and Exhibits <br />EXHIBIT A - Legal Description _ <br />EXHIBIT B - Mining Plan <br />EXHIBIT C - Map <br />/ <br />EXH IBIT D - Wildlife~Water Resources) <br />Vegetatiorl~ Soils Information <br />