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. COLORADO Poo! <br /> Division of Reclamation, <br /> Mining and Safety <br /> D.? partment of Nat•'rral Resources <br /> 1313 Sherman Street, Room 215 ce RECEIVE <br /> Denver, CO 80203 <br /> MAY 0 7 2019, <br /> DIVISION OF RECLAMA (" <br /> LIMITED IMPACT OPERATION(110(1)) MINING AND SVM <br /> RECLAMATION PERMIT �I Sw# <br /> APPLICATION FORM <br /> CHECK ONE: New Application F Conversion Application(Rule 1.11) <br /> Permit#M- - (provide for conversions of existing permits) <br /> The application for a Limited Impact I I0(1) Mining Operation Reclamation Permit contains three major parts: (1)the application form; <br /> (2) Exhibits A-J, any required sections of Exhibit S and Geotechnical Stability Exhibit, as required by the Office, and outlined in Rules <br /> 6.1, 6.2, 6.3, and 6.5; and (3) the application fee. When you submit your application, be sure to include one (1) signed and notarized <br /> original and one(1)copy of the application form,two(2)copies of Exhibits A-J,and 6.5(Geotechnical Stability Exhibit),as required,and <br /> a check for the application fee described under(4)below. Exhibits should not be bound or in a 3-ring binder;maps should be folded to 8 <br /> 1/2"X I I"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 described below <br /> 1. Applicant/operator or company name(name to be used on the permit): - U IJTCJ v <br /> 1.1 Type of organization(corporation,partnership,etc.): —T AJ/V t cC U <br /> 2. Operation name(pit,mine or site name): cJ <br /> 3. Permitted acreage(must be 5 acres or less): 4 permitted acres <br /> 4. Fees: <br /> 4.1 New Application $288.00 application fee <br /> 4.2 Amendment Application $661.00 amendment fee <br /> 4.3 Conversion Fee(from 110(2)to I I0(1),(Rule 1.11.2(2)) $288.00 conversion fee <br /> 5. Primary commoditie(s)to be mined: /v d N e 1 1 <br /> 6. Name of owner to the surface of affected land: <br /> 7. Name of owner to the subsurface rights of affected land: 5 1 C`J e l ✓wl e <br /> 8. Type of mining operation: _a Surface F] Underground Oplacer tjor4E <br /> 1313 Sherman Street, Room 215, Denver,CO 80203 P 303.866.3567 F 303.832.8106 http://mining.state.co.us <br /> John W. Hickentooper, Governor I Mike King, Executive Director I Virginia Brannon, Director <br />