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- i <br />7/78 III III III IIIIIIIIII ~ APPLICATION CHECKLIST . 77Y <br />REGULAR 112 APPLICATION NAME I~~/r!~"~(~l-L FILE rY S3~ <br />COMPLETE (FILED) DATE 9' 6 - 7~/ <br />---------------------------------------------------------------------------------------------- <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />2. Name of applicant <br />3. Address t; phone, local <br />4. Address b phone, general / <br />V <br />5. Person to contact / <br />I <br />6. Parent Corporation, if any / <br />I <br />7. Surface Owners V <br />8. Mineral Owners <br />9. Source of Legal Right-to-Enter ~ y <br />10. Type of Mine/Substance ~/ <br />11. General Location E Elevation ~/ <br />12. County ~ <br />13. Acreage / <br />14. Fee ~ <br />15. Present Land Use <br />16. Surrounding Land Uses / <br />/ <br />17. Proposed Future Use / <br />V <br />18. Unpermitted Mining Operations / <br />19. Affected Lands i/ <br />20. Signature <br />(aver) <br />