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• • <br />MINED LAND RECLAhWTION <br />Application ~rlorksheet/Checklist <br />Reoular 112 Application <br />Name (~{/ <br />Complete <br />IT Eh <br />III IIIIIIIIIIIIIIII <br />999 <br />~~iYo. U~-G/3 <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br />2. IVame 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 />if. Mineral Owners <br />U. Source of Legal Right-To-Enter <br />lO. Tyoe of Ftine/Substance <br />11. General Location & Elevation <br />12. County <br />13. Acreage <br />]4. Fee <br />15, Present Land Use <br />10, Surrounding Land Uses <br />17. Proposed Future Use <br />