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7/78 • APPLICATION CHECKLIST • III III III IIIIIIIIII <br />_ sss <br />REGULAR 1 12 APPLICATION NAME ~ ' ~ ' Ro u~'-r"^ F I LE 1! 7 9-7b <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 v <br />3. Address ~ phone, local v <br />4. Address & phone, general (/ <br />S. Person to contact <br />6. Parent Corporation, if any <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 E Elevation <br />12. County <br />13. Acreage <br />14. Fee ~'"~,e <br />N ,K <br />15. Present Land Use v <br />16. Surrounding Land Uses v <br />17. Proposed Future Use <br />18. Unpermitted Mining Operations v <br />19. Affected Lands / <br />/ <br />~ <br />20. Signature / <br />(over) <br />