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'~ • iiiiiiiiiiiiiiuiii • <br />999 <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />Regular 112 Application Name i -e. BY~~ rile No.~S'Uq <br />Complete Fi ed Uate ~i~~d5 <br />ITEM COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation ` <br />X <br />2. Name of Applicant/Operator <br />3. Address 6 Phone (local) <br />4. Address & Phone (General) <br />5. Person to Contact <br />6. Parent Corporation, if any <br />7. Surface Owners <br />ti. Mineral Owners <br />9. Source of Legal Right-To-Enter <br />10. Type of Mine/Substance <br />11. General Location & Elevation <br />12. County <br />13. Acreage <br />14. fee <br />15. Present Land Use <br />16. Surrounding Land Uses <br />17. Proposed Future Use <br />