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- ~ • III IIIIIIIIIIIII III • <br />999 <br />MINED LAfVD RECLAMATION <br />Application Worksheet/Checklist <br />GaldwaU Bros. <br />Regular 112 Application Name ~~ fdwr(I :f #F " File No.M 8"6_orb <br />Complete (Filed Date >•"e /o, ly8'6 <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br />2. Name 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 />ti. Mineral Owners <br />9. Source of Legal Right-To-Enter <br />10. Type of Mine/Substance <br />11. General location & Elevation <br />12. County <br />13. Acreage <br />14. Fee <br />15. Present Land Use <br />lo. Surrounding Land Uses <br />17. Proposed Future Use <br />