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<br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />Limited Impact (110) <br />Special 10-Day (111) <br />Name <br />Comp <br />File No..~-l-~S- /5~~ <br />ITEM <br />ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br />/ <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 Bt M <br />7. Mineral Owners <br />8. Source of Legal Right-To-En er '~ / ~"~~`~' {° ;<.~"~"„ <br />/~ cfa.,....~ <br />9. Type of Mine/Substance ,/ <br />10. General Location & Ele ation ~/ <br />11. County / <br />12. Acreage i/ <br />13. Fee <br />14. Present Land se ,~ <br />15. Proposed Fu ure Use <br />16. Signature <br /> <br /> <br />