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APPLICANT'S QUESTIONNAIRE <br />For Limited Impact Operations <br />(Permit 110-1 and 110-2) or <br />Regular Operations Permit 112) <br />Appendix A. Exhibit H-1 Page 1 <br />TO THE COLORADO DIVISION OF WILDLIFE <br />Instructions to theapplicant: Complete both sides of this form. Send the completed <br />form to the appropr ate Division of Wildlife (DOW) Regional Manager. Regional - <br />Managers <br />NW Region: 711 Independent Avenue Grand Junction, CO 81505 NE <br />Region: 317 W. Prospect Avenue Ft. Collins, <br />Central: 6060 Broadway Denver, CO 80216 <br />SW Region: 2300 S. Townsend Avenue Montrose, CO 81401 SE <br />Region: 2126 N. Weber Colorado Springs, CO 80907 <br />To expedite processing, please provide the information in the format and order <br />described in this form. Type or print clearly. Incomplete questionnaires will be <br />returned. Please allow 30 days for processing of completed form. Your cooperation is <br />appreciated. <br />PLEASE ATTACH THE FOLLOWING INFORMATION TO THIS FORM: <br />A. Mining and Reclamation Plan: Description of proposed reclamation plan or submit <br />Mining and Reclamation Plan as prepared for MLRD application. <br />B. Vis: Submit copies of maps for the both the Mining Plan and the Reclamation <br />an. Suggested maps are those prepared for the MLRD application. <br />For the 110-1 Permit, Two Acre Limited Impact Operation: Exhibit A - Location Map <br />Exhibit C - Affected Lands Map. <br />For the 110-2 Permit, Limited Impact Operation: Exhibit E - Mining Plan Map and <br />Reclamation Plan Map. <br />For the 112 Permit, Regular Operation: Exhibit C - P -e -Mining and Mining Plan <br />Map(s) of Affected Lands, and Exhibit F - Reclamation Plan Map. <br />1. Operation name (pit, mine): Smith Pit No. 20 - Amendment No. 1 <br />2. Application type (check one): <br />3. Name of applicant/operator: <br />Moffat County Board of County <br />Commissioners- In care of: <br />Moffat County Road Department <br />P.O. Box 667, Craig, CO 81626 <br />Phone Number(970)824-3211 <br />Two Acre Limited Impact Operation (110 - <br />Limited Impact Operation (110-2) <br />Amendment to: Regular Permit Operat-on (112)XXXXX <br />4. Name of contact person (if different from above): <br />Billy E.Mack (Director) Moffat County Road Department k <br />Address P.O. Box 667, Craig, CO 81626 <br />Phone Number: (970)824-3211 <br />5. Location of mine: Moffat County, T12N, R93W,_Section 18, NW1/4 NW 1/4 <br />(County, Township, Range, Section to nearest quarter quarter) <br />