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<br /> <br /> <br /> <br />eg '~ '" III I <br /> <br />MINED LAfJiI RECLAMATION <br />Application Worksheet/Checklist <br />ular 112 Application Name a-c~ <br />Complete Filed Uate IIIIIIIIIIIII <br />999 <br /> <br /> <br />File iVO.p y <br />i 8 <br /> <br /> ITEM C1)hiPLETE ADEQUATE CUMMEIVTS <br />App <br />1. lication Form: <br />iVame of Operation <br />2. IVame of Applicant/Operator <br />3. Address & Phone (Local) <br />4. Address & Phone (General) <br />5. Person to Contact <br />6. Parent Corporation, if any <br />7. Surface Owners <br />D. Mineral Owners <br />9. Source of Legal Right-To-Enter <br />10. Type of Mine/Suostance <br />11. General Location & Elevation <br />12. County <br />13. Acreage <br />la. Fee D~ <br />15. Present Land Use <br />lo. Surrounding Land Uses <br />17. Proposed Future Use <br />