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7/7$ IIIIItlllllllllll{I <br />sss <br />REGULAR 112 APPLICATION <br />APPLICATION CHECKLIST <br />• <br />NAME ~aS,~o~.a-(t P~~M~ ILE <br />COMPLETE (FILED) DATE <br />IFEM COMPLETE ADEQUATE <br />COMMENTS <br />~ 7y-86 <br />Application Form: <br />1. Name of operation <br />2. Name of applicant ~ <br />3. Address 6 phone, local / <br />( <br />/ <br />4. Address 6 phone, general ~ <br />5. Person to contact <br />6. Parent Corporation, if any <br />7. Surface Owners <br />8. Mineral Owners ~ ! <br />i <br />3. Source of Legal Right-to-Enter <br />10. Type of Mine/Substance <br />11. General Location ~ 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 <br />(over) <br />