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7/78 APPLICATION CHECKLIST <br /> REGULAR 112 APPLICATION NAME I l e R°b 5 a /3 r c6 d -r;"-e, FILE <br /> ✓k $o —ma`s <br /> o <br /> COMPLETE (FILED) DATE <br /> ---------------------------------------------------------------------------------------------- <br /> ITEM COMPLETE ADEQUATE COMMENTS <br /> Application Form: / <br /> I . Name of operation v <br /> I <br /> 2. Name of applicant <br /> 3. Address b phone, local <br /> 4. Address b phone, general <br /> 5. Person to contact <br /> 6. Parent Corporation, if any <br /> 7. Surface Owners <br /> 8. Mineral Owners 4/ <br /> I <br /> 9. Source of Legal Right-to-Enter r , <br /> 10. Type of Mine/Substance ,o-r <br /> 11 . General Location b Elevation <br /> 12. County <br /> 13. Acreage <br /> 14. Fee Nh n <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 />