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III IIIIIIIIIIIIIIII <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />Limited Impact (110) <br />Special 10-Day (111) <br />File No. M-S~6-I`(1 <br />ITEM <br />Name~jEe.Y~~(,y I~CQC~N'M~,r roncvc~Q <br />Complete filed Date <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br />~( <br />Y <br />2. Name of Applicant/Operator <br />3. Address & Phone (Local) \! <br />/\ <br />4. Address & Phone (General) <br />5. Person to Contact ~/ <br />/~ <br />6. Surface Owners V <br />/\ <br />7. Mineral Owners <br />8. Source of Legal Right-To-Enter <br />9. Type of Mine/Substance ~ ~ OnPk ~if ~"` ~'~" <br />10. General Location & Elevation <br />11. County l~C~n~ <br />12. Acreage a <br />/ ~.~~ <br />13. Fee. ( 2 ). ~- <br />14. Present Land Use }~ <br />/` <br />, <br /> <br />15. Proposed Future Use <br />~/ <br />j\ ,~- <br />16. Signature <br />5:~ •f <br />