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7/78 ~ APPLICATION CHECK/L,I/ST <br />REGULAR 1 12 APPLICATION NAM EC-C/o~~•~~ +~ ~ r~G~l LE ~`~~ 7 7 - <br />-------COMPLETE (FILED) DATE y,..~~, ! /~__ <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />2. Name of applicant - I <br />3. Address b phone, local <br />4. Address E phone, general <br />5. Person to contact `~ <br />- <br />6. 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 />l2. County <br />13• Acreage <br />14. Fee <br />15. Present Land Use <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 />