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STATE OF COLORADO
<br /> DIVISION OF RECLAMATION,MINING AND SAFETY
<br /> Dept of Natural Resources
<br /> 1313 Sherman St.,Roan 215 AI RR 2 0 2022
<br /> Denver,Colorado 80203 CO LO RADO
<br /> Phone:(303)866.3567 mnntvrscomv o
<br /> FAX:(303)832.8106 DIVISION OF RECLAMATION RECCLLA�T O
<br /> MINING AND SAFETY _
<br /> SAFETY
<br /> DESIGNATED MINI G
<br /> LIMITER IMPACT (1JOd)OPERATiO
<br /> RECLAMATIO PERMIT APPLICATION FORM
<br /> CIIECK ONE: ew Application(Rule l.4} Amendment Application(Rule 1.8 or 1.10)
<br /> Conversion Application(Rule 1 11}
<br /> Permit#M- ,,,_ ,,,,_,,, (provide for Amendments and Conversions of existing permits)
<br /> The application for a Limited Impact(I 1 Od)Designated Mining Operation Reclamation Permit contains three major parts: (1)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 6.1,6.2,6.3,6A.20 6.5,8,and 1.6.2(I)(b);and(3)the application fee.When you submit your applicati on,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 I(Rule 1 A2(1)(b)),as req wired,and a check for
<br /> the application fee described under(4)below. Exhibits should QT he 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 /> GE ERAL OPERATIO I FORMATIO
<br /> Type or print clearly,in the space provided,all Information described below,
<br /> 1, r comRM namen it: JACK D TABB, LLC
<br /> 1.1 Type of organization(corporation,partnership,etc.): LLC — — — — — — — — — — — — — — — — — — —
<br /> 1.2 I.R.S.Tax ID No.or Social Security umber:
<br /> 2. Operation name(nit.mine or site.name): Gu N N ELL MINE _ _ - . - - - - - - _ -
<br /> 3 Permitted acreage(new 7r exist to site): 1.38 _ r permitted acres
<br /> 3.1 Change in acreage(+) , _ _ _ _ acres
<br /> Total Acreage in Permit Area 1.38 sores
<br /> 4 Eff.(Ririe I.5)
<br /> 4.1 ew Application S2,875,00 application fee
<br /> 4.2 Amendment Fee(operations existing as of0 6/30/94) SI.725.00 application fee
<br /> 4.3 Amendment Fee(operations permitted from 07101194) S2,300.00 application fee
<br /> 4.4 After July 1,199 5,to convert a 110(I),110(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 52,875.00(Rule 1.11.2(2)).
<br /> 5. Primaa commodides to be mined. Au,!4
<br /> 6. Tyne of miming opgration: le Surface Underground In-situ
<br /> Office of Office of
<br /> Mined Land Reclamatim Denver •Grand Juncdon • Durango Active and Inactive Mines
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