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'/'$ III IIIIIIIIIIIII III .LIST <br />• 999 • <br />REGULAR 1 12 APPLICATION NAME Q.,.. 4a. ( 5 SG..-.~ G~ . F I LE R~3 _~ <br />COMPLETE (FILED) DATE <br />---------------------------------------------------------------------------------------------- <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />2. Name of applicant J' <br />3. Address & phone, local i ~~ <br />4. Address E phone, general <br />I <br />5. Person to contact / <br />// <br />6. Parent Corporation, if any i <br />7. Surface Owners <br />8. Mineral Owners <br />9. Source of Legal Right-to-Enter <br />10. Type of Mine/Substance /' <br />l/ ~ <br />il. General Location & Elevation <br />12. County <br />13. Acreage <br />4. Fee /~ <br />`/ <br />15. Present Land Use ~ <br />16. Surrounding Land Uses <br />17. Proposed Future Use / ~ <br />( <br />~ <br />18. Unpermitted Mining Operations I i <br />h <br />19. Affected Lands l~ <br />20. Signature / <br />(over) <br />