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7/78 III IIIIII~IIIIIIIII • APPLICATION CHECKLIST • <br />REGULAR 112 APPLICATION NAMEL'~:..., C,~„sl`r~c'.o~~ CNe~Tp t~S FILE /~ 7/-75 <br />COMPLETE (FILED) DATE ~~~'~Fl~ <br />---------------------------------------------------------------------------------------------- <br />1TEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />2. Name of applicant <br />.. ,. <br />;•'~ <br />3• Address ~ phone, local I v <br />/\ <br />4. Address E phone, general ~ x <br />5• Person to contact ~. <br />i <br />6. Parent Corporation, if any ~ ~ <br />7. Surface Owners x <br />8. Mineral Owners ,/ <br />9. Source of Legal Right-to-Enter ~~ <br />10. Type of Mine/Substance <br />11. General Location E Elevation <br />12. County ~ ,, <br />13. Acreage ~ `~ <br />/~ <br />14. Fee ~ ~ <br />15. Present Land Use <br />16. Surrounding Land Uses <br />17. Proposed Future Use v <br />/~ ~---~=~=-~;~-~' <br />.~~ -~- <br />18. Unpermitted Mining Operations <br />19. Affected Lands v <br />/ <br />~ <br />20. Signature ~ ~ <br />(over) <br />