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<br />Regular 112 Application <br />ITEM <br />III I I) I I~ I I~ I~~I II~ <br />MINED LAND RECLAMATION <br />Application Work sheetjChecklist <br />Name ~^~px,~Virv~ Yd.J '(.,~b„,~,dFile No. ~-(~-v <br />Complete sled Date <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation GCSk FOB ~w <br />2. Name of Applicant/Operator <br />3. Address & Phone (Local) ~ <br />4. Address & Phone (General) v <br />5. Person to Contact ~ <br />6. Parent Corporation, if any ,/ Wosd-f'~., -/~laht(~ <br />7. Surface Owners <br />~ <br />~r <br />8. Mineral Owners ~ ,~ <br />9. Source o~ Legal Right-To-Enter ~ ~ 1 <br />10. Type of f4ine/Substance ~ S~ G <br />11. General location & Elevation v S ~i C ~$ ~- <br />12. County <br />13. Acreage <br />14. Fee <br />15. Present Land Use ~ <br />16. Surrounding Land Uses v /1 ~ ~5~~~ <br />/` <br />~ <br />17. Proposed Future Use v d <br />~ y: ~~ <br />~M <br />~"~" <br />