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7/7fi III IIIIIIIIIIIIIIII <br />REGULAR I12 APPLICATION <br />ITEM <br />PLICATION CHECKLIST <br />NAME ( av~- ~ . FILE <br />COMPLETE ( ILED) DATE <br />~ 79-187 <br />COMPLETE ADEQUATE COMMENTS <br />APplic:ation Form: <br />1. Neime of operation , / <br />" <br />2. Neime of applicant t/~ <br />3• Address 6 phone, local <br />c~ <br />4. Address & phone, general c` <br />5. Person to contact <br />v~ <br />6. P:3 rent Corporation, if any <br />7. Surface Owners C~ <br />S. Mineral Owners ~ <br />9. Source of Legal Right-to-Enter ~ <br />!~ <br />10. Type of Mine/Substance ~~ <br />11. General Location E Elevation v <br />12. County ~ <br />13• Acreage <br />14. Fee <br />15. Present Land Use ~. <br />16. Surrounding Land Uses Ll <br />17. Proposed Future Use `~ <br />1fi. Uipermitted Mining Operations <br />19. Affected Lands ~/ <br />20. Signature (~` <br />(over) <br />