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~... ~ • iii iiiiiiiiiiiiuii • <br />999 <br />MINED LANU Ktt;t,HriH~1vN <br />Application Worksheet/Checklist <br />Regular 112 Application Name (-~„~-F,,/,P~i,~,e,~ur, File No.~ <br />Complete filed ate <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application form: <br />1. Name of Operation v <br />~l y <br />/1 <br />2. Name of Applicant/Operator ~/ <br />3. Address & Phone (Local} ,/ <br />/I <br />4. Address & Phone (General) ,/ <br />/ ,/ <br />5. Person to Contact ~ X <br />6. Parent Corporation, if any _---- <br />7. Surface Owners ~ ~, <br />S. Mineral Owners <br />~''~ <br />X <br />9. Source of Legal Right-To-Enter lj <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 X ~,,. <br />16. Surrounding Land Uses X ~ <br />17. Proposed Future Use , / ,/ <br />