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7/78 APPLICATION CHECKLIST <br />• >_ <br />REGULAR 1 12 APPLICATION NAME CofYl CGnS~-. -,°,1 7j li ~ , ~i ~ FILE #'_ <br />COMPLETE (FfLED) DATE .~ - ~ 7 ` T ~/ <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />I. Name of operation <br /> <br />i <br />i <br /> <br />2. Name of applicant <br />/ <br />~ _ <br />3. Address 6 phone, local <br />4. Address E phone, general / <br />5. Person to contact ~..- <br />6. Parent Corporation, if any v <br />7. Surface Owners <br />8. Mineral Owners <br />v <br />9. Source of Legal Right-to-Enter / <br />/ <br />10. Type of Mine/Substance ~ <br />ll. General Location E Elevation <br />12. County ~ <br />13. Acreage <br />14. Fee <br />15. Present Land Use <br />(J <br />16. Surrounding Land Uses > <br />17. Proposed Future Use <br />L/ <br /> <br />18. Unpermitted Mining Operations <br />) _ <br />19. Affected Lands J <br />20. Signature / <br />(over) <br />