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~~ • III IIIIIIIIIIIIIIII i <br />999 <br />MINED LAfVr) RECLAMATION <br />Application Worksheet/Checklist <br />Regular 112 Application iVame - - File iV~• M-~y-n99' <br />Complete Filed Date ~/7/,~'~ <br />T~ <br />ITEM CUh1PLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation ~a;.p <br />~ <br /> P ~~ <br />Z. !Name of Applicant/Operator <br />3. Address & Phone (Local) 'Y~ <br />4. Address & Phone (C~neral) +/ <br />5. Person to Contact ~ <br /> <br />6. Parent Corporation, if any ~/~- <br />'° <br />7. Surface Owners <br /> <br />d. itineral Owners ~ <br />9. Source of Legal Right-To-Enter <br /> <br />10. Type of Mine/Substance <br />11. General Location & Elevation 3 " ""`~`-° s c <br />12. County <br /> (n.) <br />13. Acreage <br />~/~ <br />la. Fee ~~ Gf ~ <br />~~~ <br />15. Present Land Use ~ <br />lo. Surrounding Land Uses <br />17. Proposed Future Use I / <br /> <br />