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( COLQRADO Division of Reclamation, Mining and Safety � De; .:rr:e•;t a"da:ura �eso::rc�> 1313 Sherman Street, Room 215 Denver,CO 80203 LIMITED IMPACT OPERATION(110(1)) RECLAMATION PERMIT APPLICATION FORM CHECK ONE: New Application Permit#M- - (provide for conversions and amendments of existing permits) The application for a Limited Impact 110(1) Mining Operation Reclamation Permit contains three major parts: (1)the application form; (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, 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 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 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 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. 1 GENERAL OPERATION INFORMATION Type or print clearly,in the space provided,all information described below 1. Applicant/overator or company name(name to be used on the permit): Jeff A Carter 1.1 Type of organization(corporation,partnership,etc.): Individual 2. Operation name(pit,mine or site name): Lombard#3 3. Permitted acreaee(new or existing):(must be 5 acres or less) 0.918 permitted acres 4. Fees: 4.1 New Application $288.00 application fee 5. Primary commoditie(s)to be mined: Gold &Silver 6. Name of owner to the surface of affected land: US Forest Service 7. Name of owner to the subsurface rights of affected land: US Forest Service 8. Type of mining operation: El Surface F - Underground []Placer , 1313 Sherman Street,Room 215,Denver,CO 80203 P 303.866.3567 F 303.832.8106 http://mining.state.co.us *.