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7/78 APPLICATION) CHECKLIST <br />• ~~ • ~~_ <br />REGULAR 1 12 APPLICATION NAME Uf~ L ~ l' /~ U%~'`' ~-5 °!~ F I LE /t z~ 7 <br />COMPLETE (FILED) DATE ~. ~'- ~~- ~~ <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation C ~- <br />~ ~ <br />2. Name of applicant <br />3. Address & phone, local '~ <br />I <br />4. Address E phone, general <br />5. Person to contact <br />I <br />6. Parent Corporation, if any ~ <br />7. Surface Owners <br />8. Mineral Owners <br />9. Source of legal Right-to-Enter <br />10. Type of Mine/Substance <br />11. General Location E Elevation <br />12. County <br />13. Acreage <br />14. Fee <br />15. Present Land Use <br />16. Surrounding Land Uses <br />17. Proposed Future Use <br />18. Unpermitted Mining Operations <br />19. Affected Lands ~ <br />20. Signature i <br />(over) <br />