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STATE OF COLORADO <br />DIVISION OF MINERALS AND GEOLOGY" ILC (jU r ; <br />Department of Natural Resources <br />1313 Sherman St., Room 215 FOR SCANNING RECEIVED <br />T D t v t s�OO <br />Denver, Colorado 80203 <br />FAX: f30 0 83868106 7 OCT 2 <br />3102 <br />CONSTRUCTION MATERIALS Division of Minerals and Geology <br />LIMITED IMPACT (110) OPERATION <br />MINERALS <br />GEOLOGY <br />RECLAMATION <br />MINING -SAFETY <br />Bill Owens <br />RECLAMATION PERMIT APPLICATION FORM Governor <br />Greg E. Walcher <br />Executive Director <br />Michael B. Long <br />pWv an Director <br />CHECK ONE: X New Application (Rule 1.4) Conversion Application (Rule .� <br />Amendment Application (C.R.S. 34-32.5-110) <br />Permit # M-j2Q0R`J_0J_ (provide for Amendments and Conversions of existing permits) <br />The application for a Construction Materials limited Impact (110) Operation Reclamation Permit contains three major parts: (1) the application form; <br />(2) Exhibits A-1, Exhibit L, Addendum 1, any sections of Exhibit 6.5 and Geotechnical Stability Exhibit, as required by the Office, and outlined in Rules <br />6.1, 6.2, 6.3, 6.5, and 1.6.2(1)(b); and (3) the application fee. When you submit your application, be sure to include one (1) complete signed and <br />notarized IVORY ORIGINAL and one (1) copy of the completed ivory application form, two (2) copies of Exhibits A-7, Exhibit L, Addendum 1, and <br />appropriate sections of 6.5 (Geotechnical Stability Exhibit), as required, and a check for the application fee described under (4) below. Exhibits should <br />NOT be bound or in a 3 -ring binder; maps should be folded to 8 12" X 11 " or 8 12" X 14" size. To expedite processing, please provide the information <br />in the format and order described in this form. <br />GENERAL OPERATION INFORMATION <br />Type or print clearly, in the space provided, ALL information described below. <br />I. Applicant/operator or company name (name to be used on permit): A. Blasi & Son Trucking & - Earthmoving <br />1.1 Type of organization (corporation, partnership, etc.). Cor oration <br />Inc. <br />1.2 I.R.S. Tax ID No. or Social Security Number: <br />2. Operation name (pit, mine or site nameuchar2 s : 'P i t <br />3. Permitted acreage (new or existin site): <br />3.1 Change in acreage (+) <br />Total Acreage in Permit Area <br />4. Fees: <br />4.1 New Application: <br />Amendment Fee (C.R.S. 34-32.5-125(1T)): <br />4.2 Conversion Fee (from 110d to 110 $875.00 conversion fee (Rule 1.11.2(2)) <br />5. Primary commodities) to be mined: 1 1/2 t r RB <br />_9_..`— permitted acres <br />acres <br />9.5 acres <br />$1,094.00 application fee <br />$719.00 application fee <br />5.1 Incidental commodities) to be mined: a0 .000/ 1bs/Tons/ 2. / lbs/Ions/yr 3. / !bs/Tons/vr <br />4. / Ibs/Tons/yr 5. / lbslTons/vr <br />5.2 Anticipated end use of primary commodities) to be mined: <br />5.3 Anticipated end use of incidental commoditie(s) to be mined: <br />