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- STATE OF COLORADO <br />DIVISION OF RECLAMATION, MINING AND SAFETY <br />Department of Natural Resources <br />1313 Sherman St, Room 213 <br />Denver, Colorado 80203 <br />Phone: (3031866-3567 <br />FAX: (303) 832-8106 <br />LIMfTED EVIPACT OPERATION (110(2)) <br />RECLAMATION PERMIT <br />APPLICATION FORM <br />CHECK ON_E, m New Application (Rule 1.4) -a Conversion Application (Rule 1.11) <br />Permit # M- - (provide for conversions of existing permits) <br />C-OLORADO <br />DIVISION OF <br />RECi.AMATION <br />MINING <br />SAFETY <br />The application for a Limited Impact Designated Mining Operation Reclamation Permit contains three major parts: (1) the application <br />form; (2) Exhibits A ], any required sections of Exhibit S and Geotechaiad Stability Exhibit, as required by the Office, and outlined in <br />Rules 6.1, 6.2, 6.3, 6A. 19 and 6.5; and (3) the application fee. When you submit your application, be slue to include one (1) sigMAas <br />notari7 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 cheek for the application fee described ander (4) below. Exhibits should not be bound <br />or in a 3 -ring binder, maps should be folded to 8 1/2" X I l" or 8 1R" X 14" size. To expedite processing, please provide the information <br />in the format and order described in this form. <br />GENERAL i • OPERATION INFORMATION <br />Type or print clearly, In the space provided, all information described below <br />1. Applicant/operator or company name (name to be used on the permit): AMAZON ITE MINING, LLC <br />1.1 Type of organization (corporation, partnership, etc.): LIMITED LIABILITY COMPANY <br />2. Operation nine (nit, mine or site name): FORREST MINING PROJECT <br />3. Permitted acreage (new or existing site): 9.9 permitted acres <br />4. Fees: <br />4.1 New Application _El 006.00 application fee <br />4.2 Amendment Application (from 1.10(2)) <br />43 Conversion Fee (from 110d to 110(2), (Rule 1. 11.2(2)) $1.725.00 conversion fee <br />5. Primary commoditle(s) to be mined: GEMSTONES <br />6. Name -of owner tothe surface ofaffectediland: U.S.D.A. FOREST SERVICE <br />7. Name of owner to the subsurface riehts of affected land: JEFFREY S. FORREST & BETSY C. FORREST <br />8. tae of mining operation: r Surface Underground ler-situ <br />RECEIVED <br />APR 0 4 2017 <br />TELLER COUNTY <br />CLERK & RECORDER <br />Office of Office of <br />Mined Land Reclamation Denver " Grand )unction • Durango Active and Inactive Mines <br />