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<br />4/77 <br />MINED LA+~1D RECLAMATION <br />LIMITED ItIPACT AND SPECIAL 10-DAY PERI~fIT APPLICATION CHECKLIST <br />File No. ~.3a~Name '~T ~rl~ Date of Filing (Completeness) <br />ITEM COMPLETE ADEQIIATE COMMEi1TS <br />Application Form <br />1. Name of operation <br />f <br />2. Name of applicant/operator ~ <br />3. Address & phone (local offices) ~ <br />4. Address & phone (general offices) ~ <br />5. Person to contact / <br />6. Surface ocmers ~/ <br />7. ifineral owners ~' <br />8. Type of mine/substance V, <br />9. General location 6 elevation ~ <br />10. County f <br />11. Acreage ~ <br />12. Fee /~ <br />13. Present land use ,/~ <br />14. Proposed future use ~/ <br />15. Signature <br />Maps and Exhibits <br />1. Exhibit A - Legal description <br />/ <br />{a <br />2. Exhibit B - :fining plan ~- <br />3. Exhibit C - Map V <br />4. Exhibit D - Wildlif2~Water Resources, <br />Vegetatib~and Soils Li.etfor- <br />mation <br />5. Exhibit E - Reclamation plan /~ <br /> <br />