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4/77 ~ ~ ~ 111 --- -- ----- <br />1111111111111111 <br />MINED LAi~tD RECLAMATION <br />LIMITED IA(PACT Ai~1D SPECIAL 10-DAY PERi~!IT APPLICATION CHECKLIST <br />File No. 70^~ t.J Name Cr1~ t,QUll,i(~y" Date of Filing (Completeness) <br />ITEt4 COMPLETE ADEQUATE COMMEZTS <br />Application Form <br />1. Name of operation <br />~ <br />m <br />2. Name of applicant/operator / <br />V <br />3. Address d phone (local offices) <br />4. Address ~ phone (general offices) ~/ <br />5. Person to contact <br />6. Surface owners <br />7. :Iineral owners <br />8. Type of mine/substance V <br />9. General location ~ elevation <br />10. County <br />11. Acreage J <br />12. Fee <br />13. Present land use <br />14. Proposed future use <br />15. Signature <br />Maps and Exhibits <br />i. Exhibit A - Legal description <br />2. Exhibit B - .fining plan <br />3. Exhibit C - Map <br />4. Exhibit D - Wildlife, Slater Resources, <br />Vegetation and Soils infor- <br />mation <br />3. Exhibit E - Reclamation plan ~ ' <br />~ r'( <br />