2021-12-07_REVISION - M2012032 (13)

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U.S. Army Corps of Engineers South Pacific Division am Nationwide Permit Pre-Construction Notification (PCN) Form This form integrates requirements of the U.S.Army Corps of Engineers Nationwide Permit Program within the South Pacific Division (SPD),including General and Regional Conditions. You MUST fill out all boxes related to the work being done. Fillable boxes in this form expand if additional space is needed. Box 1 Project Name Revenue Mine Applicant Name Applicant Title Rory Williams Applicant Company, Agency, etc. Applicant's internal tracking number(if any) Silver Star Resources Mailing Address 1675 Larimer Street Suite 820 Denver, CO 80202 Work Phone with area code Mobile Phone with area code Home Phone with area code Fax # with area code 303-534-6500 E-mail Address Relationship of applicant to property: rory@slvrstar.com ❑Owner ❑ Purchaser ❑Lessee ❑ Other: Application is hereby made for verification that subject regulated activities associated with subject project qualify for authorization under a U.S. Army Corps of Engineers Nationwide Permit or Permits as described herein. I certify that I am familiar with the information contained in this application and, that to the best of my knowledge and belief, such information is true, complete, and accurate. I further certify that I possess the authority to undertake the proposed activities. I hereby grant to the agency to which this application is made the right to enter the above-described location to inspect the proposed, in-progress or completed work. I agree to start work only after all necessary permits have been received and to comply with all terms and conditions of the authorization. Signature of applicant Date (mm/dd/yyyy) If anyone other than the person named as the Applicant will be in contact with the U.S.Army Corps of Engineers representing the Applicant regarding this project during the permit process,Box 2 MUST be filled out. Box 2 Authorized Agent/Operator Name Agent/Operator Title Melani Jensen Wetland Biologist Agent/Operator Company, Agency, etc. E-mail Address WestWater Engineering maj@westwaterco.com Mailing Address 2516 FORESIGHT CIRCLE #1, GRAND JUNCTION, CO 81505 Work Phone with area code Mobile Phone with area code Home Phone with area code Fax #with area code 970-241-7076 970-241-7097 I hereby authorize the above named authorized agent to act in my behalf as my agent in the processing of this application and to furnish, upon request, supplemental information in support of this permit application. I understand that I am bound by the actions of my agent and I understand that if a federal or state permit is issued I or my agent, must sign the ermit. Signature of applicant Date (mm/dd/yyyy) I certify that I am familiar with the information contained in this application, and that to the best of my knowledge and belief, such information is true, complete, and accurate. Signature of authorized agent Date (mm/dd/yyyy) Page 1 of 10 Revised March 21,2012. For the most recent version of this form,visit your Corps District's Regulatory website.