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ins <br />APPLICATION CHECKLIST <br /> <br />REGULAR 112 APPLICATION <br />ITEM <br />NAME .~''ranc .-: r„, •) i3 FILE <br />COMPLETE (FILED) DATE <br />77 <br />a y as <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />~ <br />/ <br />2. Name of applicant <br />I <br />3. Address ~ phone, local ~ <br />4. Address ~ phone, general '~ I <br />5. Person to contact ~ I <br />6. Parent Corporation, if any ; ~ I <br />7. Surface Owners I I <br />8. Mineral Owners ~ I <br />9. Source of Legal Right-to-Enter <br />f <br />I <br />~ <br />10. Type of MinelSubstance I <br />I <br />11. General Location & Elevation <br />12. County i <br />13. Acreage ~ , / <br />V <br />14. Fee <br />15. Present Land Use <br />16. Surrounding Land Uses <br />17. Proposed Future Use ~ / <br />/ <br />18. Unpermitted Mining Operations / , / <br />v <br />19. Affected Lands ~ ~/ <br />20. Signature U/ / <br />{over) <br />