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<br />~ ~ III IIIIIIIIIIIII III <br />DIVISION OF MINERALS AND GEOLOGY <br />Limited Impact 110(2) <br />Application Worksheet/Checklist <br />New Application:/ ' ~ Amendment Application: <br />Operator: /~JRS~rrn ~5-Y?x.Uc~,~.L-~G Mine ID: ~c~ /Do2 <br />Mine Name: e~nu~~~ -aj} Qi~f Submittal Date: /O~S~9a <br />APPLICATION FORM: <br />ITEMS <br />COMPLETED 1 2 3 4 5 6 <br /> / / / <br />ITEMS <br />COMPLETED 7 8 9 10 11 12 <br /> ;~ ~ / / / / <br />MAPS and EXHIBITS <br />ADEQUACY COMMENTS <br />EXHIBIT A - LEGAL DESCRIPTION & LOCATION MAP /~ <br />EXHIBIT B - SITE DESCRIPTION <br />a. Vegetation & Soils /~ <br />b. Critical Structures within 200 feet and offsite damage `~ <br />c. Water Resources and Wildlife Statement (if provided)// <br />