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-' ~. • • III IIIIIIIIIIIII III <br />999 <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist / <br />Limited Impact (110) Name n„ ,~~` File No.~1_ ~-y_~~yC <br />Special 10-Oay (111) Complete Filed) Date ~~~ y/~ y <br />ITEh1 COMPLETE ADEQUATE COMMENTS <br />Application Fonn: <br /> C~,~„-a, F, P,-I <br />1. Name of Operation <br /> v <br />2. Natne of Applicant/Operator <br /> v <br />3. Address & Phone (Local) ~ / <br />4. Address & Phone (General) r / <br />5. Person to Contact <br /> v <br />b. Surface Owners <br /> ~ v <br />7. i4ineral Owners ,i ~ <br />8. Source of Legal Right-To-Enter <br /> <br />U. Type of Mine/Substance v <br /> ~ <br />10. General Location & Elevation <br /> <br />11. County qq <br />~'lorr~,.~ <br />/ <br />12. Acreage ~ <br /> ~, ~ <br />13. Fee <br /> v <br />14. Present Land Use <br /> <br />15. Proposed Future Use <br /> <br />/ ~ <br />16. Signature <br /> <br />1 .'~ <br />