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STATE OF COLOR� <br /> DIVISION OF RECLAMATION,MINING AND SAFETY <br /> Department of Natural Resources HAND-DELIVERED <br /> 1-313 Sherman St.,Room 215 <br /> Denver,Colorado80203 RECEIVED""'VD tCOLORAD <br /> OION OF <br /> Phone:(303)%&3567 MATION <br /> FAX:(303)832.8106 N I N G <br /> MAR 1�0 2017 —&— <br /> LIMITED]IMPACT OPERATION(110tZI SAFETY <br /> WASION OF RECLAMATION <br /> RECLAMATION PERMIT MINING AND SAFETY <br /> APPLICATION FORM <br /> Ck) t�'( ( <br /> CHECK ONE: �q New Application(Rule 1.4) Conversion Application(Rule 1.11) <br /> Permit#M'X014 - O Z. (provide for conversions of existing permits) <br /> The application for a Limited Impact Designated Mining Operation Reclamation Permit contains three major parts: (1) the application <br /> form; (2) Exhibits A-J,any required sections of Exhibit S and Geotechnical Stability Exhibit, as required by the Office,and outlined in <br /> Rules 6.1,6.2,6.3,6.4.19 and 6.5;and(3)the application fee. When you submit your application,be sure to include one(1)signed and <br /> notarized original and one(1)copy of the application form,two(2)copies of Exhibits A-J,appropriate sections of 6.4.19 Exhibit S and 6.5 <br /> (Geotechnical Stability Exhibit),as required,and a check for the application fee described under(4)below.Exhibits should not be bound <br /> or in a 3-ring binder;maps should be folded to 8 1/2"X I I"or 8 1/2"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. AP <br /> D6cant/operator or company name(name to be used on the permit): P // f �{ <br /> 1.1 Type of organization(corporation,partnership,etc.): <br /> 2. Operation name(pit,mine or site name): JCQ <br /> 3. Permitted acreage(new or existing site): permitted acres <br /> Lu <br /> 4. Fees: <br /> O U�JI^z7CG�SSt � AdZ . <br /> 4.1 New Application 00 .00 application fee <br /> 4.2 Amendment Application(from 1.10(2)) <br /> 4.3 Conversion Fee(from I IOd to 110(2),(Rule 1.11.2(2)) -9*-tt5:W conversion fee <br /> /5. Primary commodities)to be mined: l�l Gt al 1 r e'Jr77"kG OL,+ /— Z� "(i r1 Q7�Ar <br /> 6. Name of owner to the surface of affected land: / I a Y1 c{ <br /> 7. Name of owner to the subsurface rights of affected land: PCCl ( C & ye rkz y + 61 l� <br /> 8. Type of mining operation: 0 Surface Underground In-situ <br /> d Annual Fee/Report: CW <br /> No Violations <br /> Office of Office of <br /> Mined Land Reclamation Denver - Grand Junction - Durango Active and Inactive Mines <br />