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~I I I I~ ~ II I I~ ~I~~ ~I~ <br />DIVISION Gr ruivn9~ru,a ruvu GEOLOGY <br />Limited Impact 110(2) <br />Application Worksheet/Checklist <br />New App: ~ Amendment App: Conversion App: <br />Operator: nn C'o' Owl a,~Q~rr e~ei~r~- Mine ID: Q~~i -Oo27 <br />Mine Name: S'~un[y~ r~~ ~~ [ Submittal Date: 3~ 12~R3 <br />APPLICATION FORM: <br />ITEMS 1 2 3 4 5 6 <br />COMPLETED <br />ITEMS 7 8 9 10 11 12 <br />COMPLETED <br />MAPS and EXHIBITS ADEQUACY COMMENTS <br />EXHIBIT A - LEGAL DESCRIPTION & LOCATION MAP /~ <br />EXHIBIT B - SITE DESCRIPTION <br />a. Vegetation & Soils <br />b. Critical Structures within 200 feet and offsite damage <br />c. Water Resources and Wildlife Statement (if provided) / <br />