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Use Code 153 <br /> Authorization ID: FS-2700-3f(02/09) <br /> Contact Name: OMB No. 0596-0082 <br /> Expiration Date: <br /> SPECIAL USE APPLICATION FOR TEMPORARY USE PERMIT FOR OUTFITTING AND <br /> GUIDING <br /> Authority: Federal Lands Recreation Enhancement Act, 16 U.S.C. 6802(h) <br /> (Ref.: FSH 2709.11, section 41.53) <br /> APPLICATION <br /> 1. APPLICANT INFORMATION <br /> Applicant Name: Ian Schimpfle, Jason Roys Business Name: Lost Creek Mining, LLC <br /> Applicant's Complete Address: PO Box 271052 Louisville, CO 80027 <br /> Telephone Number: 303-242-0880 or 720-434-1663 <br /> E-mail Address: lostcreekmining@gmail.com Website: We do not yet have our own independent <br /> website. <br /> As an applicant, are you: <br /> _ Individual If yes, are you a citizen of the United States? <br /> X Corporation If yes, provide a copy of your state certificate of good standing. <br /> _ Limited Liability Company If yes, provide a copy of your state certificate of good standing. <br /> _ Partnership or Association If yes, provide a copy of your partnership or association <br /> agreement. <br /> _State Government or Agency (Includes state universities) <br /> _Local Government or Agency (Includes high schools) <br /> _Nonprofit (Please attach a copy of your IRS Form 990) <br /> Under the Regulatory Flexibility Act, a small entity is a firm that is "independently owned and <br /> operated" and "not dominant in its field of operation." The United States Small Business <br /> Administration has developed size standards to identify what is considered a small business. <br /> Under these standards, a business with annual receipts of less than $6.5 million constitutes a <br /> small business for recreation industries. Additionally, a small organization is any nonprofit <br /> enterprise that is independently owned and operated and not dominant in its field. A small <br /> government jurisdiction is a government of a city, county, town, township, village, school district, <br /> or special district with a population of less than 50,000. <br /> Under these criteria, are you a small entity? YES <br /> 2. DESCRIPTION OF PROPOSED ACTIVITY <br /> Please include: The number of service days requested (or quota equivalent). The anticipated <br /> number of trips and party size. Trip Itinerary with: <br /> o Starting and ending dates of the proposed operations. <br /> o Location of routes and starting and ending points for the proposed operations (include a map <br /> showing these locations). Services that will be offered to clients (identify any services that will be <br /> provided by a party other than the holder). A description of your client base or audience. A list of <br /> government facilities you propose to use, e.g., a boat launch, parking lot, or trailhead. A list of <br /> temporary improvements or signs that you propose to use. A statement of whether the proposed <br />