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• III IIIIIIIIIIIII III • <br />a~ <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />Limited Impact (110) Name ! ~y~~u~-l~l File No. ~` ~~-- <br />Special 10-Day (111) Complete fled Date <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 /> X <br />4. Address & Phone (General) <br /> X <br />5. Person to Contact <br /> X <br />6. Surface Owners <br /> <br />7. Mineral Owners <br />8. Source of Legal Right-To-Enter <br /> X <br />9. Type of Mine/Substance <br /> x <br />i0. General Location & Elevation <br /> X <br />11. County <br /> X <br />12. Acreage <br /> X <br />13. Fee <br />14. Present Land Use <br /> X <br />15. Proposed Future Use <br /> X <br />lb. Signature <br />