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/~ ~_~y <br />~_J <br />u <br />MINED LAfVD RECLAMATION II III'llllllllllll <br />Application Worksheet/Checklist <br />Limited Impact (110) Name Duve D; ezz.- °O:R~z~~ P. "File No.M-84--03~ <br />Special 10-Day (111) Complete Filed) Date -eb. i9Y r <br /> <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br /> ~ ~ <br />2. Name of Applicant/Operator <br /> ~ X <br />3. Address & Phone (Local) <br /> ~ >< <br />4. address & Phone (General) x <br />5. Person to Contact <br />x <br />x <br />b. Surface Owners <br />7. Mineral Owners <br /> X ~ <br />8. Source of Legal Right-To-Enter <br /> k x <br />g. Type of Mine/Substance <br /> X ~ <br />lU. General Location & Elevation <br /> X ~ <br />11. County <br /> X X. <br />1'Z. Acreage <br /> x <br />13. Fee <br />14. Present Land Use X <br />15. Proposed Future Use <br />16. Signature <br /> <br />