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7/78 III IIIIIIIIIIIIIIII <br />sss <br />REGULAR 112 APPLICATION <br />APPLICATION CHECKLIST <br />NAME ~a,~v ~ 5T0 ~ \ F I LE #~~ <br />COMPLETE (FILED) DATE <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />2. Name of applicant <br />3. Address & phone, local <br />4. Address E phone, general / <br />d <br />5. Person to contact / <br />f/ <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 />( <br />/ <br />11. General Location E Elevation ~ <br />12. County U <br />13. Acreage / <br />v <br />14. Fee ,A;D <br />~(C/ ~,CC~~ <br />15. Present Land Use <br />16. Surrounding Land Uses <br />17. Proposed Future Use `/ <br />18. Unpe rmitted Mining Operations (j <br />19. Affected Lands <br />d <br />20. Signature <br />(over) <br />