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.~ <br /> <br />II <br />MIIVED LAND RECLAMATION <br />Application Worksheet/Checklist <br />Limited Impact (110) Name p we,. ~,,.wt-"Fj~,,, P;t'' <br />Special 10-Day (111) Complete Filed Date k I IIIIIIII~II~IIII <br /> <br /> <br />ile No.H-YY-/s <br />9y'Y <br /> <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br /> <br />x <br />2. Name of Applicant/Operator <br />3. Address & Phone (Local) <br />4. Address & Phone (General) <br />5. Person to Contact <br />6. Surface Owners <br />7. Mineral Owners <br />8. Source of Legal Right-To-Enter• <br />9. Type of Mine/Substance <br />10. General Location & Elevation <br />11. County <br />12. Acreage <br />13. Fee <br />14. Present Land Use <br />15. Proposed Future Use R ~^-~ ^'s"~ b' <br />a• ~ f ~. ~ rR Hs <br />16. Signature <br /> <br />