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._. <br />Regular 112 Application <br />ITEM <br />MINE III'IIIIIIIIIIIIIII klist <br />Applicat yyy <br />Name N ~~la/X~ti..., C~kr ;~<>` File No. a~" ~y~ ~~ <br />Complete~iled Date Ji "i~~" <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br />2. Name of Applicant/Operator <br />3. Address & Phone (Local) V <br />4. Address & Phone (General) 'v' <br />5. Person to Contact ;~ <br />6. Parent Corporation, if any :~' <br />7. Surface Owners / <br />8. Mineral Owners ;~ <br />9. Source of Legal Right-To-Enter 4 <br />10. Type of Mine/Substance ,f <br />11. General Location & Elevation ,,. <br />12. County <br />13. Acreage <br />V <br />14. Fee ~;'~ <br />15. Present Land Use ,, <br />16. Surrounding Land Uses <br />L <br />17. Proposed Future Use ,. <br />