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:.. _:. <br />• • ~II ~I~~I~~I~II~~II~ <br />sss <br />MINED LAND RECLAMATION <br />Application Worksheet/Checklist <br />s.y..a~tie ~o,.~+y Real Qopf. <br />Regular 112 Application Name ~s „ Ss. b.( G..~er ~:+'' File iVo. H-,YY-oYrs <br />Complete Filed Uate Ftb. aT~.iy~r <br />ITEM <br />COMPLETE ADEQUATE COMMENTS <br />Application Form: <br />1. Name of Operation X X <br />2. Name of Applicant/Operator <br /> ~ ~ <br />3. Address & Phone (Local) <br /> ~ Y- <br />4. Address & Phone (General) <br /> ~ ~ <br />5. Person to Contact <br /> X K <br />6. Parent Corporation, if any <br /> ~ t <br />1. Surface Owners <br /> <br />ti. Mineral Owners <br /> x ,~ <br />9. Source of Legal Right-To-Enter <br /> ~ ~ <br />10. Type of Mine/Substance <br /> <br />11. General Location & Elevation <br /> ~ x <br />12. County <br /> x ,c <br />13. Acreage <br /> >G <br />14. Fee ~ <br /> <br />15. Present Land Use <br /> )C, x. <br />lo. Surrounding Land Uses <br /> X ~c <br />17. Proposed Future Use <br /> J~ ~c. <br />