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~r <br />• III IIIIIIIIIIIII III • <br />999 <br />MINfD LAND RECLAMATION <br />implication Worksheet/Checklist <br />C. (o. ;r. of Hwy.r. <br />Limited Impact (110) Name r ;s" File No.n-Yc-o37 <br />Special 10-Day (111) Complete i ed Date /`-~~,~c, a i. / 9PG <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br /> <br />)c <br /> <br />x <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 />