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~ + ~ ~II ~I~~I~~I~~~~~ ~I~ <br />Regular 112 Application <br />ITEM <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />Name f::. -,1~...:.._. File iVo. R~~-r°// <br />Complete Filed Uate <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br /> L <br />2. Name of Applicant/Operator ~ ~ <br /> <br />3. Address & Phone (Local) , <br /> L L <br />4. Address & Phone (General) <br /> v <br />5. Person to Contact ` ~ <br /> <br />6. Parent Corporation, if any ~ ~ <br />1. Surface Owners <br /> v <br />8. Mineral Owners ~ <br /> <br />9. Source of Legal Right-To-Enter ,, <br /> v <br />10. Type of Mine/Substance v G <br />11. General Location & Elevation <br /> <br />12. County ~ ,/ <br />13. Acreage ~ . ) 2 <br />;, <br />14. fee <br />~'~ <br />l5. Present Land Use ,~ ~ <br />16. Surrounding Land Uses / Y <br />17. Proposed Future Use / <br />v / <br />