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COLORADO <br /> Division <br /> Mining a <br /> Department 019-026 <br /> RE�LT'�v ED <br /> 1313 Shermi M2 <br /> Denver, CO �a <br /> ERR/mac #y��., ?Q} { <br /> LIMITEDRECLAMATION PERM T(110(1)) `'`^ WQM'C)CL4-MAr1ON <br /> APPLICATION FORM <br /> UFM <br /> CHECK ONE: F�l New Application <br /> Permit#M- - (provide for conversions and amendments of existing permits) <br /> The application for a Limited Impact I I0(l) 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 6.1, <br /> 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 original <br /> and one(1)copy of the application form,two(2)copies of Exhibits A-J,and 6.5(Geotechnical Stability Exhibit),as required,and a check <br /> 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 1/2"X <br /> 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 described below <br /> 1. ADWicant/operator or company name(name to be used on the permit): Michael Royer <br /> 1.1 Type of organization (corporation,partnership,etc.): Individual <br /> 2. Operation name(pit, mine or site name): LGPD2 Mine <br /> 3. Permitted acreaee(new or existing): (must be 5 acres or less) 3.67 permitted acres <br /> 4. Fees: <br /> 4.1 New Application $24.00 application fee <br /> 5. Primary commoditie(s)to be mined: Gem Quartz, Fluorite, Goethite, Amazonite <br /> 6. Name of owner to the surface of affected land: USDA US Forest Service <br /> 7. Name of owner to the subsurface rights of affected land: Michael Royer <br /> 8. Type of mining operation: a Surface F-1 Underground Placer <br /> A �O� <br /> 1313 Sherman Street, Room 215, Denver, CO 80203 P 303.866.3567 F 303.832.8106 http://mining.state.co.us <br /> \*1-9 f6 <br />