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S/77 • <br />• <br />MIiIED LAAID RECLAMATION <br />LIMITED IPIPACT AND SPECIAL 10-DAY PERiaZT APPLICATION CHECKLIST <br />File No. ~ 'I Name I}U~ n, ~~~ ~~ ~ ~ ~ ~ ~-~ Date of Filing (Completeness) <br />ITEM COMPLETE ADEQUATE COPLfE:1T5 <br />Application Form <br />L. Name of operation <br />~ <br />2. Name of apnllcaat/operator ~ <br />3. Address 6 phone (local offices) / <br />4. Address & phone (general offices) y <br />5. Person to contact <br /> <br />5. Surface ocmers <br />,/ I i <br />I <br />I <br />7. 21iae=al owners / I <br />S. Type of mine/subrgtance <br />9. Generai..H.ocation ~ elevation ~ <br />10. County ~ <br /> <br />il. Acreage~~ <br />. r -. - i <br />ZZ. e'ee <br />I3. Present land use <br />/ ~ <br />~ _ <br />Z4. Proposed future use ~ ~ <br />i <br />15. Signature / <br />?laps and Exhibits <br /> <br />1. E.ihibit A - Legal description ~.~~~ , <br />L ti <br />Z. Exhibit B - :iiniag plan ,, <br />3. exhibit C - :{ao <br />~. Exhibit D - Tdildlife, dater Resources, <br />7egetation and Soils infor- <br />mation <br /> <br />~ <br />5. E.4hibit E - Reclamation elan <br />