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<br />z ~~ <br />III IIIIIIIIIIIIIIII ~ ~ ~ ~ ~--~--~~ -~-. <br />~.,.,.~/~ MINt1irLFNU kttLAMAT <br />Application Worksheet/Checklist <br />f/-Si4-/6g <br />Limited Impact (110) Name,~.y~u /~'~s~~LFile No. <br />Special 10-Day (111) Complete Fled Date ~6~- 7 ~q. {~ y <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <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 <br />14. Present Land Use <br />15. Proposed Future Use <br />16. Signature <br />