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7178 ~ • APPLICATION C4ECKLIST . <br />_ _ REGULAR 1 12 APPL I CAT ION NAME % ed Z, Gov. F I LE /! ~-8 <br />COMPLETE (FILED) DATE S/~7/,pg <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br /> <br />2, Name of applicant I <br /> i x <br />3. Address E phone, local I <br /> ~ ~ x <br />4. Address E phone, general <br />X <br /> pL I <br />5. Person to contact '~ i <br /> ~ <br />6. Parent Corporation, if any 4 I <br /> ~7L ~ 7C <br /> <br />7. Surface Owners i <br /> <br />~ SC <br /> ~ <br />8. Mineral Owners <br /> ~ ~ X <br />9. Source of Legal Right-to-Enter I <br />~ I ~ <br />I ` <br /> ~ <br />~ <br />10. Type of Mine/Substance ( ~ I ~ <br /> <br />11. General Location b Elevation <br />12. County <br />~ I ~ I <br />13. Acreage I ~ ~ <br />14. Fee <br /> ~ JC <br />15. Present Land Use ~ <br /> ~ <br />16. Surrounding Land Uses ` / <br /> T X <br />17. Proposed Future Use P~sb`b!y ^at- <br /> ~ <br />18. Unpermitted Mining Operations <br /> ~ X <br />19. .4ffected Lands <br /> <br />20. Signature ~ <br />(over) <br />