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STATE OF COLORADO <br />DIVISION OF RECLAMATION, MINING AND SAFETY <br />Deparmlent of Natural Resources <br />1313 Sherman St., Room 215 <br />Denver, Colorado 80203 <br />Phone: (303) 866.3567 <br />FAX: (303) 832-0106 <br />REGULAR (1124) DESIGNATED MINING OPERATION <br />RECLAMATION PERMIT <br />APPLICATION FORM <br />CHECK ONE New Application (Rule 1.4.5) g Amendment Application (Rule 1.10) <br />Conversion Application (Rule 1.11) <br />Permit No. M- 2012 _032 (provide for amendments and conversions of existing permits) <br />COLORADO <br />DIVISION' oP <br />RECLAMATION <br />MINING <br />SAFE ry <br />6111 Iliav, Jr. <br />Govan w <br />Barris D. Sherman <br />133r mop Director <br />Ronald W. cawny <br />Divislon Drecw <br />Natural 8emme Tnume <br />The application for a Regular (112d) Designated Mining Operation Reclamation Permit contains three major parts: (1) the application form; <br />(2) Exhibits A -T, Geotechnical Stability Exhibit, the Emergency Response Plan, and Addendum 1, as required by the Office, and outlined in Rules <br />6.1, 6.2, 6.3, 6.4.19, 6.5, 8.0, and 1.6.2(l)(b); " (3) the application fee. When you submit your application, be sure to include one (1) shored and <br />notarized oWgal and four (4) copies of the application form, five (5) copies of Exhibits A T, Rule 6.5 Geotechnical Stability Exhibit, the <br />Emergency Response Plan, Addendum 1, and a check for the appropriate application fee ( descnbed under Section (4) on Page 2). Exhibits should <br />not be bound or in a 3 -ring binders; maps should be folded to 8 %" X 11" or 8 K" X 14" size. To expedite processing, please provide the <br />information In the format and order described in this form <br />2. <br />GENERAL OPERATION INFORMATION <br />Type or print clearly, in the space provided, all information described below. <br />Applicantlonerator or company name (name to be used on permit): <br />Fortune Revenue Silver Mines, Inc. <br />1.1 Type of organization (corporation, partnership, etc.). Corporation <br />12 T.R.S. Tax ID No. or Social Security Number: 46- 5762880 <br />Operation mane It mine or site name): Fortune Revenue Silver Mine, Inc. <br />3. Permitted acreaee: (new or existing site) <br />3.1 Change in acreage ( +) <br />31 Total acreage in Permit area <br />34.19 permitted acres <br />54.34 acres <br />88.53 <br />COMM of Office of <br />Mined laid Reclamation Deriver • Grand Junction • Durango Active and Inactive Mines <br />