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7/, III'll'llllllllllll • APPLICATION CHECKLIST ~ 77- <br />REGULAR 112 APPLICATION NAME FILE #_f_y~~ <br />COMPLETE (FILED) DATE <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />2. Name of applicant <br />3. Address & phone, local <br />4. Address 6 phone, general , / <br />5. Person to contact <br />1 <br />6. Parent Corporation, if any / <br />7. Surface Owners ~ <br />8. Mineral Owners <br />9. Source of Legal Right-to-Enter V <br />10, Type of Mine/Substance ~ ~ <br />11. General Location E Elevation V <br />12. County <br />13. Acreage <br />14. Fee <br />15. Present Land Use l/ <br />16. Surrounding Land Uses <br />17. Proposed Future Use <br />18. Unpermitted Mining Operations <br />19• Affected Lands <br />20. Signature <br />(over) <br />