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r r JAM ? J 1909 LIMITED IMPACT OPERATION (110) APPLICATION FORM I EWMAT(ON This form contains two major parts: (1) General Operation Information and (2) Exhibits A -G. When you submit your application, be sure to include two �s��nnedd� copies of the General Operation Information, two copies of Exhibits A -G, and aieck for the application fee described under (4) below. To expedite processing, please provide the information in the format and order described in this form. ,I1 GENERAL OPERATION INFORMATION _X/ e- -Type-or print clearly, in the space provided, all information described below. I.- Applicant/Operator Name: J- :iacie 1', c . 2. Operation Name (Pit, mine or site name): .T_Ruc1P site 3. Application type: Limited Impact Operation (110). 41. Application Fee for Permitted Acreage* permitted acres. ($10 x (affected acres) + $25.00).* Note permitted acreage and application fee and attach a check for this amount when you file. !plp ;.00 application fee. 5. Substance(s) to be mined (e.g., gold /silver /gravel): Win,•, GAna_;r �,A�_ 6. Owners(s),of Substance to be Mined (check applicable box(s)): 15 Private ❑ State O Federal ❑ Indian 7. Owner(s)•of Record of Affected Land (check applicable box(s)): 91 Private ❑ State ❑ Federal O Indian 8. Type of Mining Operation (check applicable box(s)): ® Surface O Underground ❑ In -situ 9. Location Information. The center of the area where the majority of mining will occur lies in: COUNTY: rrovrers PRINCIPLE MERIDIAN (check one : 6th .(Colorado ❑ 10th (New Mexico)EI Ute TOWNSHIP (write number and check aaas rection): T 3 ❑ North ® South RANGE (write number and check direction): R 46 ❑ East ED West SECTION (write number): S - QUARTER SECTION (check one): ❑--4— 0 NW ❑ SE ❑ SW QUARTER /QUARTER SECTION (check one): ® NE © NW ❑ SE Q SW GENERAL DESCRIPTION: (miles and direction i Weat from nearest town and / approximate elevation) 1 * If the operator is a unit of State or county government, an application fee is not required. A fraction of an acre must be counted as one acre for fee calculation.