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V <br />STATE OF COLORADO <br />DIWQON OF RECLAMATION, MINING AND SAFETY <br />Department of Natural Resoumes <br />1313 Sherman SL, Room 215 <br />Denver, Colorado 80203 COLORADO <br />RCl ION t O N O <br />Phone: (303) 816 6 3567 LAMAT <br />FAX 3) 106 BAR ROCKMETAL MINING MINING <br />REGULAR OPERATION (112) SAFETY <br />RECLAMATION PERMIT APPLICATION FORM <br />CHECK ONE: FA There is a File Number Already Assigned to this Operation <br />M New Application (Rule 1.4.5) F Amendment Application (Rule 1.10) <br />F - t Conversion Application (Rule 1.11) <br />V v Y 1/ Permit # M- M - 1992 045 (provide for amendments and conversions of existing permits) <br />The application for a Regular Operation Reclamation Permit contains three major parts: (1) the application form; (2) Exhibits A -S, <br />Geotec)mical Stability Exhibit and Addendum 1; and, (3) the application fee. When you submit your application, be sure to include <br />one (1) completed, signed and notarized gray original and one (1) copy of the completed application form, two (2) copies of Exhibits <br />A -S, the Geotechnical Stability Exhibit, and Addendum 1, and a check for the application fee described under Section 4 below. <br />Exhibits should = be bound or in a 3 -ring binder; maps should be folded to 8 1/2" X 11" or 8 1/2" X 14" size. To expedite <br />processing, please provide the information in the format and order described in this form. <br />1. <br />2. <br />GENERAL OPERATION INFORMATION <br />Type or print clearly, in the space provided, smell information described below. <br />Applicant/operator name: Gold Basin, LLC <br />1.1 Type of organization (corporation, partnership, etc.): Limited Liability Corporation <br />Operation name (pit, mine or site name): Gold Basin Mine <br />3. Permitted acreage (news or existing site): <br />3.1 Change in acreage (+ or -) <br />3.2 Total acreage in Permit area <br />4. Fees: <br />4.1 <br />4.2 <br />4.3 <br />4.4 <br />4.5 <br />5. <br />6. <br />7. <br />sL <br />New Application <br />New Quarry Application <br />Milling Application (Non -DMO) <br />Amendment Fee <br />Conversion to 112 operation (set by statute) <br />Primary commodide(s) to be mined: Gold <br />Name of owner of surface of affected land: Laurens Leffingwell <br />Name of owner of subsurface rights of affected land: Laurens Leffingwell <br />If 2 or more owners, refer to Exhibit O. <br />Type of mining operation: <br />Office of <br />Mined Land Reclamation <br />Placer Surface <br />Dow " Grand lwvdion • Dur&W <br />9.9 permitted acres <br />22.4 acres <br />32.3 acres <br />$2.156.00 application fee <br />$2,674.00 quarry application <br />$3,565.00 milling application <br />$1,783.00 amendment fee <br />$1,725.00 conversion fee <br />Underground In -situ <br />Office of <br />Active and Inactive Mines <br />SCANNED <br />