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<br />•'Pe1'IO1C Cya fJdlu¢): .'i~; r. ~! !;~. i;l.: Sr:'. C'..::[_•.. .,.. /S%O Jry')~/T.i~~3~~\
<br />/ OparaCion Name,. ,~: a,,~.; "1~ r:r. ~,~ 0~f~
<br />Anniberga ry Ua[2. J<~n'.:.~:y i' a10~0 ~a/s
<br />~'~ Total: :... _., ... .. ~ .. .: r, _.;~-~,~ d4d
<br />\' ,C-~'~ ~~q CBS/ ~r~' _
<br />1. a, P2r::ucced ac:'r_.~.!e. ~;_ ... r:.~_r.'., '~....,.~: s.:cE .s lcca[ed: ~yp:~+i1L~ :.
<br />~. li2\5 cl:is mine beer. ~!ran~:c.i :'L.~t•c::U~.r': ~~~-C:>:~:,1'!V;l .. ...:7>' YES Q I
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<br />Does chls mine ONc: aCe .._.i!. .: :.EaS c!::~n .2i ~V„ D~>' year's 40RE LESS !~
<br />3. Dons chls mine haze a p'':a •; r,1~ rc,.,.,,.:.::'.:~. c. '. -~.~ YES NQ
<br />d. :UCc,1 acres aff2~..._. d~..-_ .. _ .. _~~. ~ ~~ •
<br />lN~ .~~..:;_:r~:
<br />4 Tngal acrr.s recla::'.d io. .. :'c:c _ ~~__':, :Y
<br />6. Total number of acl~?, t:: coNSOxl rep'-acemenc scuyr~. ~~'~' {
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<br />a. Average thickness of v~Nso11 rel?:Ncc~l ~. '~
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<br />7. 'focal number of ar-: .;.y see';:: ,~: `~- ..
<br />a. Lt SC Sth C'19:; :. .UEC1 c .:::,. •~ [:~~~. ,. tc1, ~:' /~...~t .': a~_CG .. I
<br />~8. I'ur non-phnaad u{n:, .~:: oli, ;;: v•. cb: ou~~•>; ~.%c r.., -_i.. :cas~:d~ `~-~ ~~~-~:
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<br />a. Dace reclamac r~; r: b2yan. ~ ~r'
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<br />9. The type and apPrvx unace yual:c LCy o? fercillzers, or ~nn:c material or soil .(1{~~'r';
<br />condlcioners used for [n~' :cpsrc •,car~•--~_ `~~J:;`
<br />7i-~ ;
<br />10. Escxmac2d total au~~x ce be atfecc2ci Ln the ne>;t repocc year: ,~~)~ ~,(]~,~ 1~•
<br />11. CO,iMENTS: _\~~,arC~Y.1-]]S~ \v.\v. A. `l':%~.: ~i'• .:
<br />Please show the locar. LOn of the acre..ye (or .:ems S - 6 cn vo'_r rrap•• IndicaCe .`j,.' .
<br />the phases of the reclame,c•~n wr.:cr: rove b~e~ :::~';-=: r.=.. ..,:e:aced ~:t:r, your cimecpble.~~~-'i"",~'
<br />For phased vperac long scr, .: .laces o•. ~.. [:.c c'. or, cE:, ;r ~, a[.:i ~...~. _, -., .<,:nac xcn began. ~l'x.`5~`.
<br />•• NOTE: if Chere have I:c~: ooe:: .~ c•.n:~.u~•5 51,.x., _. _ .as'. ... .: ,! repGrc and yoU ~ ~ ,; .i
<br />prey! UUS.Y 54~.it0_C C2Cl a mhi: ~!,"I1'_.. ~..c [cc ~..~i do{i1C'CS C({E C":r[ef:C ~~uC rEdyE lq 1[2!05 2 ehrough'~' .,'" '
<br />6, then a new map Ls unn~•_c~;sary. ...aver, chls rr'usc t:e stated above __- ;',~~'~ry~~-ryry`~~
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<br />P12ase CYPe or pnnc curry:': c:,,.:::~: ,'ce-, .,.1'-:::y addrr',s, and pr.cn2 number below: .,.t,.,,:
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<br />Contact Name: ~ 7 Fhoee: r ~ ~' ~ S ~~ i`6~, ~~r
<br />Address: ~~~ L x ~ 1 i y~::;'~..
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<br />Federal Tax ID No. or Soc1a: Secur cy No.: C~ ~ U 5u ~~ Fj `-•~ ..
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