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. ~_.. <br /> <br /> <br /> III IIIIIIIIIIIII III <br />999 <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />cSo. l,/ay CU. <br />Limited Impact (110) Name e Pit " File No.M-~-r-o' <br />Special 10-Jay (111) Complete (Filed Date Fcb. 7 ~ <br /> <br />ITEh1 COMPLETE ADEQUATE COMMENTS <br />Application Forin: <br />1. iVame of Operation <br /> <br />2. Name of Applicant/Operator <br /> ~ ~ <br />3. Address & Phone (Local) <br />4. Address & Phone (General) <br /> ~ x <br />ti. Person to Contact <br /> .x <br />b. Surface Owners <br /> X <br />7. Mineral Owners <br /> <br />8. Source of Leyal Right-To-Enter <br /> y >! <br />g. Type of Mine/Substance <br /> X X <br />lU. General Location & Elevation <br /> <br />11. County <br /> K ~ <br />1"l. Acreage ~ <br />Fee <br />13 ' r=4e <br />. u <br />14. Present Land Use x <br />15. Proposed Future Use ~ <br />16. Siynature ~ " ~- s'y""r"'a <br /> X <br />~6 <br />