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` ~ III IIIIIIIIIIII I III` ~ <br /> 999 <br />DIVISION OF MINERALS AND GEOLOGY <br />Limited Impact 110(2) <br />Application Worksheet/Checklist <br />~ <br />New App: <br />Amendment App: Conversi <br />o <br />n App: <br />Operator: ~(k~ Cp(~{,~~ Mine ID: / <br />~ <br />~.3'~~8~1 <br />Mine Name: LI r1CX5-~~-OWl ~~;~ Submittal Date: IO~aZ~~3 <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 />