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l~ <br />•- • III III III III IIII III • <br />999 <br />MINED LAfVD RECLAMATION <br />Application tJorksheet/Checklist <br />tiinited Impact (I10) Name V I~ pu~b/s Co„~r~he D1~~,s~ile No.M-Erg-o~q <br />Special 10-Day (111) Complete Filed) Date ~~,~~j, ~y~ y <br />ITEh1 COMPLETE ADEQUATE COMMENTS <br />Application Forin: <br />1. Name of Operation <br /> JL <br />2. Name of Applicant/Operator <br /> <br />3. Address & Phone (Local) <br /> <br />4. Address & Phone (General) <br />5. Person to Contact <br /> 7~ ~ <br />b. Surface Owners <br /> ~ x <br />7. Mineral Owners <br /> ~ x <br />8. Source of Leyal Right-To-Enter ~ <br /> X <br />D. Type of Mine/Substance <br /> ~G x <br />lU. General Location & Elevation X <br /> x <br />11. County <br /> ~ x <br />12. Acre aye <br />13. Fee <br />14. Present Land Use <br /> <br />15. Proposed suture Use <br /> <br />16. Signature ~ X <br />