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7/78 III III III IIIIIIIIII • APPLICATION CHECKLIST • <br />REGULAR 1 12 APPLICATION NAME ov w P d ~ K F 1 LE k~ g_SJ <br />COMPLETE (FILED) DATE 2 7 <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation / <br />L/ / <br />`/ <br />2. Name of applicant / <br />3. Address & phone, local <br />4. Address b phone, general ~I <br />i <br />5. Person to contact / <br />/ / <br />6. Parent Corporation, if any ~ I <br />I ~ <br />7. Surface Owners / ~ <br />// <br />8. Mineral Owners f <br />9. Source of Legal Right-to-Enter ~~ I <br />I <br />10. Type of Mine/Substance ~ Y <br />11. General Location E Elevation <br />12. County <br />I <br />13. Acreage <br />i <br />14. Fee <br />15. Present Land Use ~ ,` y <br />16. Surrounding Land Uses ~ l~ <br />17. Proposed Future Use <br />18. Unpermitted Mining Operations <br />19. Affected Lands <br />20. Signature <br />(over) <br />