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7/]$ III'lllll'llllll I71 ~ APPLICATION CHECKL I ST~ CQS t ~9- <br />REGULAR 112 APPLICATION NAME ~~Q~iY'on i/~ClVing - /?~bdc~ FILE #~ <br />----COMPLETE-(FILED)-DATE---- S ' 3 O - `7 9 ---- <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of operation <br />2. Name of applicant ~ <br />3. Address 6 phone, local ~ <br />4. Address 6 phone, general L/ <br />i <br />5. Person to contact <br />c/ <br />6. Parent Corporation, if any <br />7. Surface Owners <br />8. Mineral Owners <br />9. Source of Legal Right-to-Enter (/ <br />10. Type of Mine/Substance v <br />11. General Location E Elevation <br />12. County <br />13. Acreage / <br />(/ <br />14. Fee <br />15. Present Land Use <br />16. Surrounding Land Uses / <br />! <br />/ <br />l7. Proposed Future Use ~ <br />18. Unpermitted Mining Operations <br />19. Affected lands <br />20. Signature ~~ <br />(over) <br />