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iii iiiiiiiiiiiii iii <br />999 <br />Regular 112 Application <br />ti <br />• <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />Name File No. <br />Complete Filed Date <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />A~pTication Form: <br />1. Name of Operation <br />2. Name of Applicant/Operator <br />3. Address & Phone (Local) ~ / <br />l~ <br />4. Address & Phone (General) <br />5. Person to Contact <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 <br />il. 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 />