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~~~_ <br />4/i7 <br />LNED LAND RECLAMATION <br />• III III'llllllllllll Riau <br />Regular (112) Permit Application Checklist <br />File :Qo.~`~OS' Name Co(orec,ae y,~e,._ Cpw..'e~ate of Filing (Completeaess): <br />ITE'id COMPLETE ADEQUATE I COZ•II•fENTS <br />Application Form <br />1. blame of operation <br />2. ,lame of applicant t/ ,j <br />3. Address fi phone (local offices) (~ - <br /> <br />4. Address fi phone (gen'1. offices) <br />~ i <br />I ~ <br />S. Person to contact ~ <br />6. Parent corporation (if any) I (~ <br />7. Surface owners ~ i <br />8. Piineral owners i <br />9. Type of mine/substance ~ i' <br />C. General location fi elevation I (~ <br />-- ~ <br /> <br />.1. County ~ z <br />~ <br />I ~ <br />.2. Acreage ~ ~~ i ~s ,,, Sao <br />.3. Fee <br />I <br />~ <br />, <br />4. Present land use ! ~ ~ <br />5. Surrounding land uses ~ [~ <br />6. Proposed future use ~ <br /> <br />7. Other mining permits / <br />v <br />3. Signature n/e„?~ S i c,,. ec.,"~~ <br />.9. Prohibited Lands Statement <br />*taps S Exhibits <br />1. Legal description v <br /> <br />2. Index map ,,~,,~Q <br />'~` <br />?. Pre-mining fi mining plan map <br /> <br />4. Pfining plan - a) timetable I J~ <br />!/ <br />- b) depth 6 thickness of ore i <br />~~ <br />hndv <br />