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<br />,_; <br />Limited Impact (110) <br />Special 10-Day (111) <br />,. <br />~II ~II~I~~I~~~~~ ~II <br />999 <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />Name hlnshi,.,.~„~„ ~(•.,• ~-, File No.;~l ~~~ <br />Complete Filed Date ,,Rr-~c~4; {qC~(-, <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br />/~ <br />/` <br />2. Name of Applicant/Operator v <br />3. Address & Phone (Local) X <br />4. Address & Phone (General) ., <br />\ <br />5. Person to Contact <br />6. Surface Owners <br />n <br />~: <br />7. Mineral. Owners ~ .• <br />8. Source of Legal Right-To-Enter <br />~. <br />9. Type of Mine/Substance ~, <br />10. General Location & Elevation , `I <br />J <br />11. County ./ <br />/ Y <br />/ <br />` <br />12. Acreage Y <br />/` ~ <br />13. Fee ~ <br />_ <br />-'0_ !^'r:SFtl~tS~':t c,°.•'E' <br />I <br />14. Present land Use y <br />/, <br />15. Proposed Future Use <br />16. Signature <br />