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. ---•. <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />Regular 112 Application Name f-v~aT4~,~ ~u/v~y PST File No. ~7"~7/ <br />Complete Filed Date <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br />_/ <br />2. Name of Applicant/Operator / <br />3. Address & Phone (Local) <br />4. Address & Phone (General) <br />5. Person to Contact <br />6. Parent Corporation, if any '- <br />7. Surface Owners <br />8. Mineral Owners / <br />9. Source of Legal Right-To-Enter <br />10. Type of Mine/Substance !/ <br />11. General Location & Elevation ~ <br />12. County <br />13. Acreage <br />3i~.~ <br />14. Fee <br />15. Present Land Use 1~ <br />16. Surrounding Land Uses ~~ <br />17. Proposed Future Use <br />