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]/]$ APPLICATION CHECKLIST <br />&''~-. <br />REGULAR 1 12 APPLICATION ~ NAME ~~/~'~~ ///' ~~' '~ '.>'U~-LF I LE # ~" <br />COMPLETE (FILED) DATE G{-'-/~ ~/ <br />~- ./' <br />ITEM ~ "= '~~--- ,'. ' <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br /> <br />1. Name of operation / / <br /> r f <br />2. Name of applicant ~. ~ •\ <br /> <br />3. Address G phone, local / <br /> <br />4. Address & phone, general ~ ~ <br /> j <br />I <br />5. Person to contact ~ <br /> ~ <br />6. Parent Corporation, if any <br />7. Surface Owners j <br /> <br />S. Mineral Owners ` ~ <br /> I <br />/ <br />9• Source of Legal Right-to-Enter i ' <br />10. Type of Mine/Substance ~ <br />i <br />Il. General location & Elevation ! <br /> f <br />IZ. County <br />13. Acreage \ <br />14. Fee •'~ <br />' <br /> ~ <br />15. Present Land Use <br /> <br />16. Surrounding Land Uses ~, <br />17. Proposed Future Use ~ <br /> % <br />18. Unpermitted Mining Operations <br />i <br />, <br /> <br />19. Affected Lands ~', <br />, <br />20. Signature ( <br />t <br />(over) <br />