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III IIIIIIIIIIIII III <br />sss <br />DIVISION OF MINERALS AND GEOLOGY <br />Limited Impact 110(2) <br />/ Application Worksheet/Checklist <br />New App: ~/ Amendment App: Conversi/on App: <br />Operator: Mine ID: 9 ~- ©7 7 <br />Mine Name: i Submittal Dat~e:n~`7~s/Qy <br />APPLICATION FORM: t.c~c(~\7~r11/~/~Q1~0-~1^.~, /~Q(,c~a-rv/~~ ~/~~,^~ ~O/t.~~C~ ~('y- "hQ~4`!t¢e~ <br />C l \M ~VL/ {Ai'A IQ P6 0. W{~~7u~ o'R~~L- r ~V . <br />ITEMS 1 2 3 4 5 6 <br />COMPLETED <br />~-C'14i1 i~./ <br /> <br />ITEMS 7 8 9 10 11 12 <br />COMPLETED ~ <br />MAPS and EXIiIBITS ADEQUACY COMMENTS <br />EXHIBIT A - LEGAL DESCRIPTION & LOCATION MAP +'o <br />EXHIBIT B - SITE DESCRIPTION <br />a. Vegetation & Soils // <br />b_ Critical Structures within 200 feet and offsite <br />c. Water Resources and Wildlife Statement (if provided) ~7~~~`z/ <br />