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,--.. <br />4/ 7 IIII ll~(1( 11««I(I~ i <br />f 999 <br />rffvEn LA,ti1D RECLerrATZOrt <br />LT"ffTED IPfPACT AND S?ECL9L 10-DAY PERialT APPLICATION CHECKLIST <br />r-ile No. Name ,?Date of Filing (Completeness):• <br />ITEi COi~LETE ADEQUATE COMME:dTS <br />Application Form <br />L. Name of operation <br />2. Name of apallcant/operator <br />3. Address 6 phone (Local offices) / <br />/ <br />4. Address S phone (general offices) / <br />~. Person to contact <br />5. Surface owners ~ ~ <br /> V• <br />7. Piiaeral owners <br />S. Type of mine/substance <br />9. General location S elevation I , <br />10. County ~ <br />" <br /> r <br />I <br />11. Acreage <br />/ <br />V <br />12. Fee <br />13. Present land use .~ ~ <br />14. Proposed future use I / <br />~/ ~ <br />I <br />I5. Signature <br />daps and Exhibits <br /> ~ <br />1. Exhibit A -Legal description / <br />2. Exhibit B - fining plan d , •_ =v ~ :....~ - _n'< <~ <br /> .-. ~~ <br />3. Exhibit C - ~fap <br />•'+. Exhibit D - 'dildlife, Water Resources, <br />7egetatioa and Soils infor- <br />mation , <br /> <br />~. Exhibit E -Reclamation plan / 'I L <br />, ~ <br /> ~; <br /> <br />.,U.. ~ ~ ,Y'L <br />1^~ „ i•( <br />/" <br />