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k <br />., <br />~~I ~I~~I~~I~~~~~~I~ <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />Limited Impact (110) Name ~n,vrno~~, Gti,,.z~ File No.,ti-Sb-oio <br />Special 10-Day (111) Complete Filed Date <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br />/ <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 N,a <br />14. Present Land Use / ~" ~ ~l <br /> <br />15. Proposed Future Use <br />/ q,~.c~r.~ <br />~Z7 <br />16. Signature <br />~~ <br />