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7/78 APPLICATION CHECKLIST <br />/1 i <br />REGULAR 112 APPLICATION NAME ~ FILE #C~~' "- / I <br />COMPLETE (FILED) DATE ~ - ~ U - ~~ <br />ITEM ~~~ <br />' COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br /> <br />/ <br /> <br />2. Name of applicant _ <br />3• Address 6 phone, local <br />4. Address E phone, general / <br />5. Person to contact <br />6. Parent Corporation, if an~~ <br />7. Surface Owners <br />8. Mineral Owners ` <br />I <br />9• Scurce of Legal Right-to-Enter -- <br />,'- i <br />' <br />/ _ <br />10. Type of Mine/Substance <br />r _ <br />_ <br />11. General Location b Elevation <br />12. County / <br />13. Acreage \ <br />14. Fee l <br />15. Present Land Use <br />16. Surrounding Land Uses ~, <br />17. Proposed Future Use ~ <br />i <br />~~ <br /> <br />18. Unpermitted Mining Operations <br />I\ _ <br />19. Affected Lands <br />J <br />20. Signature <br />(over) <br />