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7/7rllllllllllll'llllll <br />REGULAR l lZj¢r`?! (CATION <br />ITEM <br />APPLICATION CHECKLIST <br />NAME ~]c„ r.~ ~ ~c ~ is1LE <br />COMPLETE (FILED) DATE ~ <br />'~ ~/~_7_ <br />COMPLETE ADEQUATE COMMENTS <br />A~plitation Form: <br />1, Name of operation <br />/ } <br />(/ <br />2. Name of applicant <br />3. Address 6 phone, local it <br />4, Address & phone, general <br />5. Person to contact ~ <br />i <br />_ <br />5. Parent Corporation, if any <br />7, Surface Owners <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 />14. Fee <br />15. Present Land Use <br />__. <br />16. Surrounding Land Uses <br />l7. Proposed Future Use <br /> <br />18. Unpermitted Mining Operaitions i <br />19. Affected Lands y <br /> <br />20. Signature / <br />~/ <br />(ov~:r) <br />