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7/7$ APPLICATION CH ECXLIST <br />LIMITED IMPACT (110) / ~ NAME ~"~^"''" R~ ,Q-BJ: /`1~k FILE ~'7~-I9S <br />SPECIAL 10-DAY (Ill) _ COMPLETE (FILE U) DATE <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />2. Name of applicant/operator <br />3. Address E phone, local <br />4. Address 6 phone, general <br />5. Person to contact ~ I <br />6. Surface owners / <br />!/ <br />). Mineral owners <br />8. Source of legal right-to-enter ~/ <br />9. Type of mine/substance v <br />10. General location b ele~iation v <br />11. County <br />12. Acreage <br />13. Fee ~ <br />14. Present land use <br />15- Proposed future use • <br />16. Signature I' <br />Maps and Exhibits <br />EXHIBIT A - Legal Description , / <br />(/ _ <br />EXHIBIT B - Mining Plan <br />EXHIBIT C - Map . <br />EXH Id IT D - Wildlife, Water Resources, <br />Vegetation, Soils {nformation (~ <br />