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sir-~^.. --..~~ r.--- <br />~~_; <br />~ ~ ~ NfI?~IED LAND PERT APPLICANT' S QUESTIONNA~ FOR WILDLIFE <br />_~ r. .• <br />1. Name of Company: <br />2. Name of Contact <br />3. <br />4. <br />5. <br />6. <br />7 <br />8. <br />9. <br />Phone Number: ~ <br />Mailing Address: <br />Name of Mine r <br />Location of Mine: <br />Land Ownership <br />Present Land Use: <br />Proposed post-min <br />/ (2) BLM <br />Specify)' <br />10. Type of Operation: (Circle) (1 Surf ac (2) Underground <br />11. Number of surface acres disturb mining operation (not includ- <br />ing roads) ~ Qtr ~S <br />12. Miles of roads constructed, or to be constructed, associated with <br />mine operation (including exploratory roads); /~,~,.,~%e <br />13. Approximate number of years mine will be in operation: g~ <br />14. Brief description of operation and reclamation plans (Additional <br />sheet may be attached) : e ,~,: [ • ~ - S' <br />/ r ~ ~ ' ~ ~ ~ ~ J~~ <br />r - <br />•~ ,/ a P <br />_s <br />15. Please enclose a copy of a map showing the project disturbance areas, <br />and additional information on the operation, if the material is <br />available. This will help DOW expedite processing a wildlife <br />statement for your MLR application. Insufficient information on <br />project location and plans often result in a delay in providing a <br />statement. Your cooperation if appreciated. <br />16 . Prepared By : ~ ry ~~ S/`7 Date : /`j / <br />01-19-81 <br />cf <br />