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STATE OF COLORADO <br /> DIVISION OF RECLAMATION, MINING AND SAFETY RECEIVED <br /> Department of Natural Resources <br /> 1313 Sherman St,Room 215 JAN 10 2019 C O L O RA D O <br /> Denver,Colorado 80203 <br /> p[VISION O F <br /> Phone:(303)866-3567 RECLAMATION <br /> FAX:(303)832-8106 LINCOLN COUNTY MINING <br /> CLERK&RECORDER — —_ — <br /> SAFETY <br /> CONSTRUCTION MATERIALS <br /> REGULAR(112)OPERATION <br /> RECLAMATION PERMIT APPLICATION FORM <br /> CHECK ONE:FA There is a File Number Already Assigned to this Operation <br /> Permit# M ='r",;1-,';; -_ (Please reference the file number currently assigned to this operation) <br /> New Application(Rule 1.4.5) M Amendment Application(Rule 1.10) <br /> Conversion Application(Rule 1.11) <br /> Permit# M " - - '' <br /> -�.,, .I.J c 1 � - (provide for Amendments and Conversions of existing permits) <br /> The application for a Construction Materials Regular 112 Operation Reclamation Permit contains three major parts:(1)the application <br /> form;(2)Exhibits A-S,Addendum 1,any sections of Exhibit 6.5(Geotechnical Stability Exhibit;and(3)the application fee. When you <br /> submit your application, be sure to include one (1) complete sinned and notarized ORIGINAL and one (1) copy of the completed <br /> application form,two(2)copies of Exhibits A-S,Addendum 1,appropriate sections of 6.5(Geotechnical Stability Exhibit,and a check for <br /> the application fee described under Section(4)below. Exhibits should NOT be bound or in a 3-ring binder;maps should be folded to <br /> 8 1/2"X 11"or 8 1/2"X 14"size. To expedite processing,please provide the information in the format and order described in this form. <br /> GENERAL OPERATION INFORMATION <br /> Type or print clearly,in the space provided,ALL information requested below. <br /> 1. Applicant/operator or company name(name to be used on permit):• <br /> L I Type of organization(corporation,partnership,etc.): n-:I';1 <br /> 2. Operation name(pit,mine or site name): <br /> 3. Permitted acreage(new or existing site): -5-] .(,:1; permitted acres <br /> 3.1 Change in acreage(+� --- - - - - t 1� acres <br /> 3.2 Total acreage in Permit area t.=�t •. -? acres <br /> 4. Fees: <br /> 4.1 New Application $2,696.00 application fee <br /> 4.2 New Quarry Application $3,342.00 quarry application <br /> 4.4 Amendment Fee $2,229.00 amendment fee <br /> 4.5 Conversion to 112 operation(set by statute) $2,696.00 conversion fee <br /> 5. Primary commodities)to be mined: <br /> 5.1 Incidental commodities)to be mined: 1. Ibs/Tons/yr 2. / Ibs/Tons/yr <br /> 3.- / Ibs/Tons/vr 4. / lbs/Tons/vr 5. / lbs/Tons/yr <br /> 5.2 Anticipated end use of primary commodities)to be mined: <br /> 5.3 Anticipated end use of incidental commodities)to be mined: N�I aAc <br />