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'i <br /> <br />DIVISION OF MINERALS AND GEOLOGY <br />Limited Impact 110(2} <br />/ Application Worksheet/Checklist <br />New App: pV..~~~ pp QQ~~ SSlIAmendment App: Conversion App: <br />Operator: 1~p! dX~y p3P~1Q Mine ID: Qr~-~~$~ <br />Mine Name: ~xy~ ~ 7 ~Q~Q.. Submittal Date: <br />APPLICATION FORM: <br />ITEMS 1 2 3 4 5 6 <br />COMPLETED <br /> / <br /> <br />ITEMS <br />COMPLETED 7 8 9 10 11 12 <br /> ~ '~ - <br />MAPS and EXHIBITS <br />EXHIBIT A - LEGAL DESCRIPTION & LOCATION MAP <br />EXHIBIT B - SITE DESCRIPTION <br />a. Vegetation & Soils <br />ADEQUACY COMMENTS <br />b. Critical Structures within 200 feet and offsite damage <br />c. Water Resources and Wildlife Statement (if provided) <br /> <br />