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COLORADO <br /> Division of Reclamation, RECEIVED <br /> Mining and Safety CLERK $ RECORDER <br /> Department of Natural Resources FA I R P L AY. C O L O R A D O <br /> 1313 Sherman Street,Room 215 <br /> Denver,CO 80203 8,13 OCT 2 3 AD 5b <br /> LIMITED IMPACT OPERATION(110(1)) RECEivm <br /> RECLAMATION PERMIT <br /> APPLICATION FORM OCT 2 4 2u1 <br /> 9 <br /> CHECK ONE: g New Application DMSON OF RECLAMATION <br /> Permit#M-;2 0 Jq- D 3 IL (provide for conversions and amendments of existing permits) <br /> The application for a Limited Impact 110(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 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. Applicant/operator or company name(name to be used on the hermit): C}- <br /> 1.1 Type of organization(corporation,partnership,etc.): Z. L G <br /> 2. Operation name(pit,mine or site name): �o <br /> 3. Permitted acreage(new or existing):(must be 5 acres or less) i permitted acres <br /> 4. ems: <br /> 4.1 New Application $288.00 application fee <br /> 5. Primary commodide(s)to be mined: 13 rx r/ t"�P C� <br /> 6. Name of owner to the surface of affected land: L M <br /> 7. Name of owner to the subsurface rights of affected land: L. 0 R G- <br /> 8. Type of mining operation: 1X Surface F� Underground OPlacer <br /> Qt <br /> 1313 Sherman Street,Room 215,Denver,CO 80203 P 303.866.3567 F 303.832.8106 http://mining.state.co.us <br />