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]/]8 ~ APPLICATION LHcC~<LIST <br />LIMITED IMPACT (110) ~ NAME L'I`° y~ FILE <br />SPECIAL 10-DAY (Ill) COMPLETE (FILED) DATE <br />ITEM COMPLETE ADEQl1ATE COMMENTS <br />Application Form: <br />1. Name of operation <br />~ <br />2. Name of applicant/operator v <br />3. Address E phone, local v <br />4. Address E phone, general <br />5. Person to contact <br />6. Surface owners ~ <br />7. Hineral owners v <br />8. Source of legal right-to-enter <br />9. Type of mine/substance <br />10. General location E elevation <br />11. County <br />12. Acreage <br />13. Fey <br />14. Present land use <br />15. Proposed future use <br />16. Signature <br />Maps and Exhibits <br />EXHIBIT A - Legal Description <br />EXHIBIT B - Mining Plan <br />EXHIBIT C - Map . <br />EXH 131T D - Wildlife, Water Resources, <br />Vegetation, Soils Information I / <br />!!!/// <br />