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9 <br />MINED LAND RECLAf4ATI0N <br />Application Worksheet/Checklist <br />w~~~~ ~byivr°I <br />Limited Impact (110) Name /t.~ o~ ti i`'-''w'~~^~ File No.di ~ ib <br />Special 10-Day (111) Complete riled) Daie i;~ - ~ -,~,~ <br />ITEh1 COMPLETE ADEQUATE COMMENTS <br />App <br />1. lication Fonn: <br />iVame of Operation <br />X <br />2. Name of Applicant/Operator k <br />3. Address & Phone (Local) ~, <br />4. Address & Phone (General) X <br />5. Person to Contact X <br />ti. Surface Owners <br />7. Mineral Owners <br />8. Source of Legal Right-io-Enter <br />D. Type of Mine/Substance <br />10. General Location & Elevation <br />11. County <br />12. Acreage <br />13. Fee <br />14. Present Land Use I <br />15. Proposed Future Use ~'~ <br />16. Signature <br />/v cz-o <br />~- <br />