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DIVISION OF MINERALS AND GEOLOGY <br />CONSTRUCTION MATERIALS <br />Regular (112) Mining Operation <br />Application Worksheet/Checklist <br />New App: Amendment App: Conversion App: <br />Operator: Mn ~f ('„ ~,~ ~Q,,,, d fjQ ,~~_ Mine ID: /l~~ .-h <br />Mine Name : ~';,, ~, (~ n,, ,„ /~~.} ~ ~ ~ Rec Date : S'~7- ad <br />APPLICATION FORM (Rule 1.6.2 and 1.6.3j: <br />ITEMS 1 2 3 4 5 6 <br />COMPLETED <br /> / / +~ <br /> / / / / / / <br />ITEMS 7 8 9 10 11 12 <br />COMPLETED <br /> /~ .~ / / ~ / <br /> / / / / / / <br />ITEMS 13 14 Description Responsibilities Signature <br />COMPLETED of of a <br /> A <br />m <br />dment <br />en permittee r/ <br /> n <br />/ <br />~ <br /> b~ 4 ~ h~~ <br /> <br /> <br />MAPS and EXHIBITS (Rule 6.2) <br />ADEQUACY COMMENTS <br />EXHIBIT A - 6.4.1 - LEGAL DESCRIPTION: / <br />EXHIBIT B - 6.4.2 - INDEX MAP: / <br />