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b 1A1 t Ul CULUK� <br /> DIVISION OF RK LAWTf0N,MtMNG AND SAFETY <br /> Deparbnentof Na" <br /> 1313 Sherman St.,Room 215 <br /> Denver,Cdwado W2D3 C-O L O RA D O <br /> Phone:t3U3)M&3567 n r v r s t o x o <br /> RE <br /> fao031 s32-a106 MINING <br /> N <br /> G <br /> x: <br /> LUMTED IMPACT OPERATION(110(2)) SAFETY <br /> PERMIT <br /> APPLICATION FORM <br /> QI CONE: MNewApplication(Rnie 1.4) f I ConvasionApplic Wm(Rule 111) <br /> Permit#M- - (Provide for conversions of existing Permits) <br /> The application for a t mied Impact Designated Mining Operation Reclamation Permit corm three major}ruts: (1)1he application <br /> form;(2)Exhibits A J,any regnined secuons of Exhibit S and Geote Mcal Stability Exhiib14 as regumd by the Office,and outlined m <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 we(1)jigmd and <br /> d orioW and me(1)car of the application fmm,two(2)copies of Exhibits A-1,appropriate sections of 6.4.19 Ulibit 5 and 6.5 <br /> (Geotech nical Stability Exhibit),as required,and a check for the application fee described under(4)below.Exhibits should not be bound <br /> or in a 34*bbxkrt,maps should be folded to 8 In"X i l"or 8 1/2"X 14"size. To expedite pig,please provide the information <br /> m the fnramit and order descnbad m this form. <br /> [:T.AtERAL OPERATION INFORMATION <br /> Type or print may,is the space Provided,sill information described below <br /> 1. A flooerator_ or com HU nacre(none to be used on the Der+a k): AMAZON ITE MINING, LLC <br /> 1.1 Type ofaaganbation(corporation,parbwship,etc.): LIMITED LIABILITY COMPANY <br /> 2. Oweratiou name Wt.mine oraitenam): FORREST MINING PROJECT <br /> 3. Putted stayam tsaw or existm ante)• 9.9 permitted ac m <br /> 4. Few; <br /> 4.1 New Application S1.006.00 application fee <br /> 4.2 AxnandzuentApp]icatiom(fcomm 1.10(2)) <br /> 4.3 Conversion Fee(from l 10d to 110(2),(Rule 1.11.2(2)) $1.725.00 conversion fee <br /> 5. Primary eomnmoditie(sZ,to be GEMSTONES <br /> 6. Name ofowinerto the su ter-ceof affected land: U.S.D.A. FOREST SERVICE <br /> 7_ Name of owner to the subsurface rights of affected land: <br /> JEFFREY S. FORREST& BETSY C. FORREST <br /> ,/8. of m�o�Homm: surface ❑ underground RECEIVED❑ m�iam <br /> APR 04 2017 <br /> TELLER COUNTY <br /> CM <br /> ERK b RECORDER <br /> Office of Office of <br /> Mined Land Rechmodon Denver - Grand Junction - Durango Adive and khmove Mines <br />