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<br />-2- <br /> <br />3. Address and Phone Number of 3~'3 :,s y-~yir - zs'9 - 3 7 37 <br />Local Offices ~ - / , <br />4. Address and Phone Number of <br />General Offices <br />~c;~ avi <br />5. Name and Phone Number of Person ~ <br />Staff Members Should Contact ~ <br />~a~,~U lei o ~ IS r•ucr ~l~c~ <br />6. Owner(s) of Record of Affected Land ~,.~/ <br />(surface area) (If more than 2, list below) ~a`~``~ 3 <br />7. Owner(s) of Substance to be Mined ~~4``~`,' ~ (~rdC.e ~ct~ <br />(If more than 2, list below) <br />8. Source of Legal Right-To-Enter C2w~i~v-_ "TC17C ~~~~~ <br />(Indicate what type of proof is <br />included in EXHIBIT G -lease, <br />deed, notarized letter, etc.) <br />9. Type of Mine and Substance to be Mined G~~ c.i p,~f - ~'~ <br />(Specify underground, open pit, <br />quarry, etc. & substance(s) to <br />be mined) <br />10. General Location and Elevation ~pr-1-~ 01- ~~,yt-i~l>!! C~'o, Oh C,(~,•5~1 <br />(Miles & direction from nearest Qp:-;: ,,;.-,oaf-/~ 1,,,.tj <br />town & approximate site elevation) <br />t? ~LV ^ ~Od~ ~ /~p9rc~ x, <br />11. County l,q~~a /~~ <br />12. Acreage of Affected Lands G 7 3 <br />(Total surface acreage to be <br />included in permit) <br />13. Application Fee (See applicable ~ 5 ~D' o0 <br />Rule to determine amount) <br />