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7/78 ~ • APPLICATION CHECKLIST III III I II I IIIIII III 7~T <br />LIMITED IMPACT (110) _ NAME~~ FILE # (J~~ <br />SPECIAL 10-DAY (111) _ COMPLETE~ED) DATE 9 ~L -7Q <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: Z <br />1. Name of operation <br />2. Name of applicant/operator I/ <br />3. Address 6 phone, local ~ <br />4. Address E phone, general ~ <br />S. Person to contact ~ <br />6. Surface owners ~ <br />7. Mineral owners // <br />8. Source of legal right-to-enter / <br />9. Type of mine/substance <br />10. General location & elevation <br />ll. County <br />12. Acreage <br />13. Fee / <br />14. Present land use ~/ <br />15. Proposed future use ~ <br />16. Signature / <br />Maps and Exhibits <br />EXHIBIT A - Legal Description <br />/ <br />EXHIBIT 8 - Mining Plan ~ <br />EXHIBIT C - Map <br />EXH IBIT D - Wildlife, Water Resources, <br />Vegetation, Soils Information v <br />