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7/78 III IIIIIIIIIIIIIIII . PPLICATION CHECKLIST • <br />REGULAR 1 12 APPLICATION NAME / F I LE ~ S°'-F ~~ <br />COMPLETE (FILED) DATE //G~.•a.~ S, / 7 $~t7 <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />C~ <br />2. Name of applicant ~- <br />3. Address b phone, local c~ <br />4. Address 6 phone, general _ <br />r/' <br />5. Person to contact ,~--rl - <br />6. Parent Corporation, if any <br />7. Surface Owners <br />8. Mineral Owners J <br />9. Source of Legal Right-to-Enter ~ <br />10. Type of Mine/Substance <br />11. General Location b Elevation <br />12. County <br />13. Acreage <br />L~ <br />14. Fee <br />Ll <br />i <br />15. Present Land Use <br />c~ <br />16. Surrounding Land Uses <br />~- <br />17. Proposed Future Use ~ <br />18. Unpermitted Mining Operations <br />19. Affected Lands <br />20. Signature <br />(over) <br />