Free R-301 - Indiana

R-301
State Form 2190 (R/9-01)

DIVISION OF RECLAMATION INDIANA DEPARTMENT OF NATURAL RESOURCES
PLAN OF REVEGETATION

I,

as the responsible official of Company depose and say:

That we have graded or otherwise prepared for revegetation in accordance with the specified land use objective(s) as stated in the approved Plan(s) of Reclamation. The below listed area(s) are to be revegetated during 20 in compliance with Indiana Code 14-36-1.

Permit Number

Location

Acres

Water, Roads, Etc.

Species, Amounts, Methods, Etc.

Signature: Title: Date:

APPROVED BY: Bruce A. Stevens, Director Division of Reclamation

Date: