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For Limited Impact Operations <br />(Permit 110 -1 and 110 -2 ) or <br />Regular Operations (Permit 112) <br />APPENDIX B. <br />MINED LAND WILDLIFE STATEMENT <br />Instructions to the Applicant: Submit this Wildlife Statement to MLRD as part of the <br />MLRD application. <br />Instructions to DOW District Wildlife Manager: Review the attached Applicant's <br />Questionnaire, complete this form, and send both back to the Regional Office. <br />Instructions to DOW Regional Staff: Send completed copies of both the Applicant's <br />Questionnaire and Wildlife Statement along with pertinent correspondence to the <br />applicant, MLRD, and DWM. <br />The following information pertaining to wildlife is provided for use by the Mined Land <br />Reclamation Board in its consideration of a mining permit for: <br />1. Name and type of mine: <br />2. Location of mine: <br />3. List threatened or endangered species (federal or state) and other species of <br />special concern present: <br />4. Assess expected impacts to fish and wildlife populations and habitat from project: <br />(OVER) <br />-12- <br />