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w ~- ,. <br />• ~II II~II~I~~I~~~ ~I~ • <br />sss <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />G,fl. of L...ncr <br />Limited Impact (110) Name ~• r. _:.~~ •f° file No. M_ -~sy. <br />Special 10-Day (111) Complete Filed Date /}u~ may, ~y~~. <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br /> ~ X <br />2. Name of Applicant/Operator <br /> K <br />3. Address & Phone (Local) <br /> ~ x <br />4. Address & Phone (General) <br /> ~ x <br />5. Person to Contact <br /> ~ x <br />6. Surface Owners <br /> <br />7. Mineral Owners <br /> X ~c <br />8. Source of Legal Right-To-Enter <br /> X <br />9. Type of Mine/Substance <br /> ~ ~ <br />10. General Location & Elevation ~ <br /> x <br />11. County <br /> X X <br />12. Acreage <br /> .x x <br />13. Fee <br />< ieo M~~~ <br /> ? <br />14. Present Land Use <br /> ~ X <br />15. Proposed Future Use <br /> <br />16. Signature <br /> <br />