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7/78 APPLICATION CHECKLIST <br />G'o~~ ~s? <br />REGULAR 112 APPLICATION NAME -30~ '~o'fD /"~ r FILE <br />COMPLETE (FILED) DATE ~c T / 9 i 9 ~ ~ <br />---------------------------------------------------------------------------------------------- <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />2. Name of applicant ~ <br />3. Address E phone, local <br />4. Address b phone, general <br />5. Person to contact <br />.~- <br />6. Parent Corporation, if any ,voT c~s7~`~ <br />O~ <br />7. Surface Owners <br />8. Mineral Owners <br />s <br />9. Source of Legal Right-to-Enter ~~ <br />I <br />10. Type of Mine/Substance <br />i <br />11. General Location 6 Elevation <br />12. County / <br />13. Acreage <br />14. fee O <br />15. Present Land Use ~ <br />16. Surrounding Land Uses // j <br />l7. Proposed Future Use / <br />18. Unpermitted Mining Operations <br />/ <br />19. Affected Lands / <br />20. Signature <br /># B~~-ZZ~ <br />(over) <br />