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~ ~ III IIIIIIIIIIIII III <br />MINED LAWb RECLAMATION <br />Application Worksheet/Checklist <br />Regular 112 Application Name %eir~[os/9.olcs /r file iVo. 77-~P ~ <br />Complete (Filed Uate <br />ITEM COh1PLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation v ~ <br />2. IVame of Applicant/Operator <br />3. Address & Phone (Local) - / <br />(/ v <br />4. Address & Phone (General) / <br />5. Person to Contact <br /> <br />t/ v <br />6. Parent Corporation, if any ~ ~ <br />7. Surface Owners j <br />// <br />tt. f~tineral Owners ~ ~ <br />9. Source of Legal Right-To-Enter / (/ <br />10. Type of Mine/Substance <br /> v v <br />11. General Location & Elevation ~ <br />12. County (/ <br />13. Acreage ~ <br />14. fee <br />15. Present Land Use v <br /> V <br />lo. Surrounding Land Uses <br /> <br />17. Proposed Future Use / l/ <br />