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STATE OF COLORADO <br /> DIVISION OF RECLAMATION,MINING AND SAFETY �e <br /> Department of Natural Resources <br /> ' AM01 <br /> D APR �72021 COLORAD PI 4-045 t violation DIVISION of <br /> M201 RECLAMATION <br /> F� ERW)dmlawa <br /> Compliedi DIVISION OF RECLAMATION MINING <br /> 2 Minor Infractions Mli NG AND SAFETY SAFETY <br /> DESIGNATED MINING <br /> LIMITED IMPACT(110d)OPERATION <br /> RECLAMATION PERMIT APPLICATION FORM <br /> CHECK ONE: New Application(Rule 1.4) DAmendment Application(Rule 1.8or 1.10) <br /> Conversion Application(Rule 1.11) <br /> Permit#M- 2014 045 (provide for Amendments and Conversions of existing permits) <br /> The application for a Limited Impact(110d)Designated Mining Operation Reclamation Permit contains three major parts: (])the application <br /> form;(2)Exhibits A-J,Exhibit L,Exhibit T,the Geotechnical Stability Exhibit,the Emergency Response Plan,and Addendum 1,as required by <br /> the Office,and outlined in Rules 6.1,6.2,6.3,6.4.20 6.5,8,and 1.6.2(1)(b);and(3)the application fee. When you submit your application,be sure <br /> to include one(1)signed and notarized Original and one(1)copy of the application form,two(2)copies of Exhibits A-J,Exhibit L,Exhibit T,the <br /> Geotechnical Stability Exhibit(Rule 6.5),the Emergency Response Plan(Rule 8),and Addendum 1(Rule 1.6.2(1)(b)),as required,and a check for <br /> the application fee described under(4)below. Exhibits should NOT be bound or in 3-ring binders;maps should be folded to 8 2"X 1 I"or 8 2" X <br /> 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 permit): Mineral Mountain Gold, LLC <br /> 1.1 Type of organization(corporation,partnership,etc.): LLC <br /> 1.2 I.R.S.Tax ID No.or Social Security Number: Not for Public Record <br /> 2. Operation name(pit,mine or site name): Mineral Mountain Project <br /> 3. Permitted acreage(new or existing site): 9.5 permitted acres <br /> 3.1 Change in acreage(-) 0.0 acres <br /> Total Acreage in Permit Area 9.5 acres <br /> 4. Fees: (Rule 1.5) <br /> 4.1 New Application $2,875.00 application fee <br /> 4.2 Amendment Fee(operations existing as of 06/30/94) $1,725.00 application fee <br /> 4.3 Amendment Fee(operations permitted from 07101/94) $2.300.00 application fee <br /> 4.4 After July 1,1995.to convert a 1 10(1),1 10(2)or a 110 to a 110(d),a new application form for a 110d must be submitted,along <br /> with an application fee of$2,875.00(Rule 1.11.2(2)). <br /> 5. Primary commodities to be mined: Gold and any associated minerals <br /> 6. Type of mining operation: F1 Surface Q Underground El In-situ <br /> Office of Office of <br /> Mined Land Reclamation Denver • Grand Junction • Durango Active and Inactive Mines <br />