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= -= = , iii iiiiiiiiniii iii • <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />Limited Impact (110) Name S A File No .f -Q ~!5 <br />Special 10-Day (111) Complete it d a e y < Cs <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br />r/ <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 ~ 9 <br />13. Fee '~ <br />~ i~ <br />14. Present Land Use ~ <br />15. Proposed Future Use / <br />71 6,,j I <br />16. Signature <br />