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-Y <br />• III III III III IIII III • <br />999 <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />/tob:.r.~ fjrsch Lam, <br />Regular 112 Application Name DD '' File No. M- ~-d76 <br />Complete Fi]ed Uate ~1ati,3, r9~Y <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation <br />2. Name of Applicant/Operator / <br />3. Address & Phone (Local) i/ <br />4. Address & Phone (General) <br />5. Person to Contact <br />6. Parent Corporation, if any <br />7. Surface Owners .V <br />il. Mineral Owners <br />9. Source of Legal Right-To-Enter <br />10. Type of Mine/Substance <br />11. General Location & Elevation / / <br />~ <br />/ <br />12. County ~ / <br />13. Acreage ,/ <br />14. Fee <br />15. Present Land Use / V <br />lo. Surrounding Land Uses <br />17. Proposed Future Use ~ , / <br />