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7/78 • APPLICATION C4ECKLIST • <br />__ _ __ REGULAR 1 12_APPL I CAT ION III III III IIIIIII III NAME Gke~.enne C~~ ~ P F M.Z F 1 LE 'n 7-/0 <br />__ _ 999 COMPLETE (FILED) DATE ~Tw ~,. / ~ yc's <br />-- ~~_~_~--_--~-~_~-_------~-__~-_-~~_~_~_~__~-------------~___--~~y -------_----____. <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />I. Name of operation <br /> <br />2. Name of applicant <br />3. Address E phone, local I <br /> X <br />4. Address E phone, general <br />I <br />5. Person to contact <br /> x <br />6. Parent Corporation, if any ~ <br />X ' <br /> I <br />7. Surface Owners ~ X <br />I <br />8. Mineral Owners x <br />9. Source of Legal Right-to-Enter ~ ` <br /> <br />10. Type of Mine/Substance <br /> ~ ~ x <br />ll. General Location b Elevation <br /> X <br />12. County <br />I <br />13. Acreage <br />I <br /> n X <br />14. Fee <br /> x <br />15. Present Land Use <br /> <br />16. Surrounding Land Uses <br /> <br />17. Proposed Fucure Use <br /> <br />18. Unpermitted Mining Operations <br /> K <br />19. Affected Lands <br /> x <br />20. Signature <br /> x <br />(over) <br />