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7/78 ^~~~~~~~ APPLICAT{ON CHECKLIST • IIIIIIIIIIIIIIIIIII <br />/(vim I 99s ~l~ <br />REGULAR 112 APPLICATION NAME ~~~~ 5~ b FILE ~ (Y ~02~ <br />--------------------------------------------COMPLETE-(FILED--DATE- ~IJ aye lu(~ <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />2. Name of applicant .1p~ 1N[uPa~~ L <br />Iv ~ `Cv <br />3. Address E phone, local <br />( <br />/ <br />4. Address E phone, general / <br />5. Person to contact <br />6. Parent Corporation, if any / <br />v i <br />7. Surface Owners ~ ~ <br />i <br />8. Mineral Owners ~/ I <br />9. Source of Legal Right-to-Enter <br />10. Type of Mine/Substance ~/ <br />ll. General Location E Elevation <br />12. County <br />13. Acreage <br />i 4. Fee ~ G ~f}c~ °~ <br />c,. r rc~~l'Nc sS <br />15• Present Land Use ~- <br />16. Surrounding Land Uses <br />17. Proposed Future Use ~ <br />18. Unpermitted Mining Operations <br />19. Affected Lands <br />20. Signature <br />(over) <br />