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STATE CIF COLORADO <br /> DIVISION OF RECLAMATION,MINING AND SAIcETI' <br /> Depanti»att of Natural Remm-es <br /> 1113 Sherman St.,Room 215 <br /> Dew,CbWado 80203 C O L D IL A D O <br /> Phone (303)8663567 DI Y t d l o n o f <br /> RECLAMATION <br /> FAX(303)$32-4106 MINING <br /> LIMITED INIPACT OPERATION(110(2)) SAFETY <br /> RECLAMATION PERMIT <br /> APPLICATION FORM <br /> CHECK Qj+ New Application(Rule 1.4) Q Conversion Application(Rule 1.11) <br /> Perinit#M-1977 -410 (provide for convemiom of existing permits) <br /> The application for a Linuted Impact Designated Mining Operation Reclamation Permit contains throe major parts: (1) the application <br /> form; (2)Exhibits A-J, any required sections of Exhibit S and Geotectmical Stability Exhibit, as required by the Office,and outlined in <br /> Rules 6.1.6.2.6.3.6.4.19 and 6.5;and(3)the application fec. When you submit vour application.be sure to include one(I)siggpd <br /> to original and one(1)copy of the application form, two(2)copies of Exhibits A-J,appropriate sections of 6.4.19 Exttibit S and 6.5 <br /> (Geotechmcal Stability Exhibit),as rcyuired,and a check for the application fee described under(4)below. Exhibits should lZ be bound <br /> or in a 3-ring binder;maps should be folded to 8 1/2" X l I" or 8 1/2" X 14" size. To expedite processing.please provide the it f iort <br /> 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. 60ucantlWratt_ or or egmg)tgv name(aame to be used on the permit): Grand Island Resources, LLC (GIR) <br /> 1.1 Type of organization(corporation, partnership,etc.): Partnership <br /> 2. Operation name(ait,mine or site aamel: Cross Gold Mine <br /> 3. brmitted acreage(new or erg s att site): 9.99 permitted acres <br /> 4, UIi <br /> 4.1 New Application S1,UU6,000 _ application fee <br /> 4.2 Amcndmcnt Application(from I.10(2)) <br /> 4.3 Conversion Fee(from 110d to 110(2).(Rule 1.11.2(2)) $1.725.00 conversion fee <br /> s. <br /> y conunaitle(slto be molted: Gold and Silver <br /> 6. Now of owner to die anrfaee of rFlected Ia»d: Grand Island Resources, LLC <br /> 7. Name of owner to the littbt<ttrface rights of affected land: Grand Island Resources, LLC <br /> 8. Tie of mining operation: Surface a Underground In-situ <br /> Office d Office of <br /> Mined land Reclamation Denver • Grand junction • Durango Active and Inactive Mines <br />