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-rz): <br />• (COLORADO <br />Division of Reclamation, <br />Mining and Safety <br />Department of Natural Resources <br />1313 Sherman Street, Room 215 <br />Denver, CO 80203 <br />r/M- 2015 -020 <br />CHECK ONE: t - i New Application <br />Permit # M- - <br />RECEIVED <br />t,-, APR 15 2015 <br />DIVISION OF RECLAMATION <br />MINING AND SAFETY <br />LIMITED IMPACT OPERATION (110(1)) <br />RECLAMATION PERMIT <br />APPLICATION FORM <br />FConversion Application (Rule 1.11) <br />(provide for conversions of existing permits) <br />The application for a Limited Impact 110(1) Mining Operation Reclamation Permit contains three major parts: (1) the application form; <br />(2) Exhibits A -J, any required sections of Exhibit S and Geotechnical Stability Exhibit, as required by the Office, and outlined in Rules <br />6.1, 6.2, 6.3, and 6.5; and (3) the application fee. When you submit your application, be sure to include one (1) signed and notarized <br />original and one (1) copy of the application form, two (2) copies of Exhibits A -J,and 6.5 ( Geotechnical Stability Exhibit), as required, and <br />a check for the application fee described under (4) below. Exhibits should not be bound or in a 3 -ring binder; maps should be folded to 8 <br />1/2" X 11" or 8 1/2" X 14" size. To expedite processing, please provide the information in the format and order described in this form. <br />(r-(L. 1 <br />2 <br />3. <br />GENERAL OPERATION INFORMATION <br />Type or print clearly, in the space provided, all information described below <br />Applicant/overator or company name (name to be used on the permit): Red Rock Exploration <br />1.1 Type of organization (corporation, partnership, etc.): LLC <br />Operation name (ait, mine or site name): Sara Rose <br />Permitted acreaee (must be 5 acres or less): <br />4. Fees: <br />4.1 New Application <br />4.2 Amendment Application <br />F1 <br />6 <br />4.3 Conversion Fee (from 110(2)to 110(1), (Rule 1. 11.2(2)) <br />Primary commodities) to be mined: Rhodocrosite <br />Name of owner to the surface of affected land: BLM / USFS <br />7. Name of owner to the subsurface rights of affected land: Michael J. Bergmann <br />8. Type of minine operation: fi Surface • Underground OPlacer <br />2.1 permitted acres <br />$288.00 application fee <br />$661.00 amendment fee <br />$288.00 conversion fee <br />gr < f)h . <br />1313 Sherman Street, Room 215, Denver, CO 80203 P 303.866.3567 F 303.832.8106 http: / /mining. state.co.us <br />John W. Hickenlooper, Governor I Mike King, Executive Director I Virginia Brannon, Director <br />