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]/7$ III'IIIIIIIIIIII'11 • APPLICATION CHECKLIST • <br />REGULAR 1 ~[ r,rni,999~,i iun NAME FILE ~` <br />COMPLETE (FILED} DATE <br />---------------------------------------------------------------------------------------------- <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />/ <br />2. Name of applicant <br />3• Address 6 phone, local / <br />/ <br />4. Address & phone, general / <br />/ <br />5• Person to contact <br /> <br />6. Parent Corporation, if any <br /> (U•: <br />7. Surface Owners <br />8. Mineral Owners / <br />/ <br />9• Source of Legal Right-to-Enter ~~ <br />10. Type of Mine/Substance / <br />11. General Location b Elevation V <br />12. County <br />13. Acreage ,/ nt/~,:, ~ .3 <br /> :G >„ - <br />14. Fee r <br />L/ ~ ~ ~ „~,,,~ <br />15• Present Land Use <br />16. Surrounding Land Uses / <br />`/ <br />17. Proposed Future Use / <br />`/ <br />18. Unpermitted Mining Operations 3 ^ic;.,<%~ ~~'~ G/~`~~`~ <br /> ~~~_~ <br />%,~- <br />19. Affected Lands ~ <br />20. Signature <br />(over) <br />