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<br /> <br />,. <br />-2- <br />3. Address rind Phone Number of <br />Local Ofi'ices ,~ <br />~~~ ~r r~~ ~,~~ , <br />~. <br />4. Address Bind Phone Number of <br />General Offices ~- <br />jQ>- ~~'4--3s~~ <br />5. Name and Phone Number of Person <br /> Staff Members Should Contact ~ ~ _ <br /> <br />6. Owner(s) of Record of Affected Land <br /> (surface area) (If more than 2, list below) <br /> <br />1. Owner(s) of Substance to be Mined <br /> (If more than 2, list below) <br /> <br />8. Source of Legal Right-To-Enter <br /> (Indicate what type of proof is <br /> included in EXHIBIT G - lease, <br /> deed, notarized letter, etc.) <br />9. Type of Mine and Substance to be Mined <br />(Specify underground, open pit, <br />quarry, e~~c. & substance(s) to <br />be mined) ~ _ <br />10. General Location and Elevation ,~< ~ ~ <br />(Miles & ciirection from nearest <br />town & ap~~roximate site elevation) r <br />mil/ CA: t J1 '~~AR[-[=L ~ r', /~~Gi~L- <br />11. County ~~ r L ~ T~ <br />12. Acreage of Affected Lands <br />(Total surface acreage to be Ci,9 <br />included in permit) <br />1~ /-I ~- ~'C- 5 <br />13. Application Fee (See applicable .s <br />Rule to determine amount) ~ ) ,,,.~ <br />