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<br />~ ~ III IIIIIIIIIIIIIIII <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist~"f~~•• %~ - ~d <br />Regular 112 Application Name/• `,,. ~~'• "o~,/ r.~., File No. / / <br />Compyete Filed Date ~Cf~~gS <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br /> ~/ <br />1. Name of Operation <br />2. Name of Applicant/Operator ,/ <br />3. Address & Phone (Local) <br /> L <br />4. Address & Phone (General) , <br /> ~ <br />5. Person to Contact <br /> ~~ <br />6. Parent Corporation, if any <br /> i <br />7. Surface Owners <br /> ` <br />8. Mineral Owners <br /> s <br />9. Source of Legal Right-To-Enter <br /> <br />10. Type of Mine/Substance <br /> <br />11. General Location & Elevation <br /> <br />12. County <br />i <br />13. Acreage <br />14. Fee ~ =' '' '' ~ '~~ <br />15. Present Land Use <br />16. Surrounding Land Uses <br /> <br />17. Proposed Future Use ~• <br />So 7..i <br />IG~ ;o S <br />Sc .z .; <br />~~ .S <br />