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7/78 <br />• <br />REGULAR 112 APPLICATION <br />APPLICATION CHECK`L'IST <br />NAME ~f~~~~. ~~aN~ P~ r FILE .4 ~~-~II <br />COMPLETE (FILED) DATE <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />2. Name of applicant / <br />/ <br />3• Address & phone, local <br />4. Address b phone, general <br />5. Person to contact ~ <br />6. Parent Corporation, if any <br />7. Surface Owners / <br />[ <br />/ <br />S. Mineral Owners , / <br />9• Source of Legal Right-to-Enter / „rj~~,l ~; <br />l./~' <br />10. Type of Mine/Substance <br />11. General Location E Elevation / <br />I,/ <br />12, County L' <br />13. Acreage <br />14, Fee ~ <br />V <br />15. Present Land Use <br />L~ <br />16. Surrounding Land Uses <br />17. Proposed Future Use v <br />18. Unpermitted Mining Operations !/ <br />19. Affected Lands '~ <br />20. Signature <br />(over) <br />