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ICOLORADO <br /> Division of Reclamation, <br /> Mining and Safety <br /> Department of rratuml Resources <br /> 1313 Sherman Street,Room 215 <br /> Denver,CO 80203 <br /> I.UMMI)IMPACT OPERATION(110(1)) <br /> RECLAMATION PERMIT <br /> APPLICATION FORM <br /> CHECK ONE NewApplication <br /> Permit#M - 11,�1 (provide for conversions and amendments of existing permits) <br /> The application for a Limited Impact 110(I) 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 /> 6.2,63,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(Geotechnicai 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 /> 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 /> 1)pe or print clearly,in the space provided,all information described below <br /> I. Auplicant/ooerator or company name(name to be used on the permit): Robert and Lauren Berry <br /> 1.1 Type of organization(corporation,partnership,etc.): Individuals <br /> 2. Operation name(pi*t mine or site name): Robert Michael#1-A <br /> 3. Permitted acreage(new or eking):(must be 5 acres or less) .03 permitted acres <br /> 4. Fees: <br /> 4.1 New Application $288.00 application fee <br /> 5. Primary commoditie(S)to be mined: Gemstonequality pebbles and or crystals for use in jewelry <br /> 6. Name of owner to the surface of affected land: <br /> 7. Name of owner to the subsurface rights of affected land: Robert and Lauren Berry through BLM Mining claim <br /> B. Type of mining operation: Surface Underground - <br /> ..oF'�t <br /> ;mac--==�--_�:�`•o <br /> 1313 Sherman Street,Room 215,Deriver,CO 80203 P 303.866.3567 F 303.832.8106 http://mining.state.co.tu <br />