Free Form R-200 - Indiana

R-200
State form 2193(R/9-01)

DIVISION OF RECLAMATION INDIANA DEPARTMENT OF NATURAL RESOURCES REPORT OF AFFECTED AREA (Please Type or Print) Permit Year: Permit No.: TO ,

, (Print Name of Operator) having received a permit to engage in surface mining, hereby submits the following maps in compliance with the Indiana Code 14-36-1: The attached map is a true plat and correct description of the land surface mined under the above permit. The attached map has been drawn by a registered surveyor to a scale of feet to an inch and includes acres affected by the mining operation during the permit year. The individual pits covered under the above permit are listed below by name with their respective locations and acreages. PIT NAME OR NUMBER AFFECTED ACREAGE SECTION TWP RANGE COUNTY

Pit entrance roads advanced The above acreage includes Section , Township

feet. Pit entrance roads graded acres redisturbed by the mining operation in , Range , County of

feet.

.

Signature Title Date