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7/78 ~~ III'lllllllllllllll ~ECKLIST <br />LIMITED IMPACT (110) / sss AME ~"ti~FO'r'a"^~' C8j'"5~ CO' FILE #7a"~Q' <br />SPECIAL 10-DAY (111) _ COMPLETE (FILED) DATE <br />---------------------------------------------------------------------------------------------- <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />~~/ <br />2. Name of applicant/operator <br />3. Address E phone, local <br />4. Address E phone, general <br />5. 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 E elevation <br />11. 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 />EXHIBIT B - Mining Plan <br />EXH181T C - Map i~- <br />EXH IBIT D - Wildlife, Water Resources, <br />Vegetation, Soils Information ~~~~ ~ <br />0 .v `~ <br />v <br />