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.._., <br />• ~II ~I~~I~~I~~~~~ II~ <br />sss <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />Limited Impact (110) Name File No. 8 y - ~s G <br />Special 10-Day (111) Complete Filed Date ~„_ed 30, i4F'y <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br />/ <br />v <br /> ~ <br />2. Name of Applicant/Operator ~ <br /> <br />3. Address & Phone (Local) ~ <br /> v <br />4. Address &' Phone (General) v <br /> v <br />5. Person to Contact <br /> v / <br />6. Surface Owners <br /> ~ ~ <br />7. Mineral Owners ` v <br />8. Source of Legal Right-To-Enter <br />~3L M <br />/ <br />9. Type of Mine/Substance <br />s~ G <br />~ <br />10. General Location & Elevation <br />i 8 ~ <br />~ ~ <br />11. County ~ <br />e <br /> <br />12. Acreage 9 6 <br />4 <br /> <br />13. Fee ~, <br /> <br />14. Present Land Use ~ ~, <br />15. Proposed Future Use ~~ ~ <br /> <br />16. Signature <br /> U <br />ti <br />,-=~ CQ <br />