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• iii iiiiiiiiiiiiiiii r^-~,~-,,,~D 999 ~ECEI~/ED OCT 1 19~~ ] ~ , LIMITED IMPACT OPERATION (110(2)) Mined Land i APPLICATION FORM ~~eclamation Division Recia~~~u,,,,,, ,;;,,ision The Application fora Limited Impact Operation Reclamation Permit contains three major parts: (1) the Application Form, (2) the Application Exhibits A-F, and (3) the application fee. When you submit your Application, be sure to include two si ned copies of the Application Form, two copies of Exhibits A-F, and a check for the app ica ion fee described under (4) below. To expedite processing, please provide the information in the format and order described in this form. GENERAL OPERATION INFORMATION Type or print clearly, in the space provided, all information described below. --------------=-------------------------------------------------------------------------- ----------------------------------------------------------------------------------------- 1 . Applicant/Operator Name: rw A v u, ~ fit. °!- T a r~vy /}. M ~ Tom. h eL.L 2. Operation Name (Pit, mine or site name): M ~ i ~.hQ ~~ 1~~ T ~ Z _ 3. Application type: Limited Impact Operation (110). 4. Application Fee for Permitted Acreage* /o, S permitted acres. (E10 x (affected acres) + E25.00).* Note permitted acreage and application fee and o0 ~` attach a check for this amount when you file. 9~~ application fee. 5. Substance(s) to be mined (e.g., gold/silver/gravel): (~ rave L 6. Owners (s) of Substance to be Mined (check applicable box(s)): Private _ State _ Federal _ Indian 7. Owner(s) of Record of Affected Land (check applicable box (s )): a'1 Private _ State _ Federal _ Indian 8. Type of Mining Operation (check applicable box (s )): ~ Surface _ Underground _ In-situ 9. Location Information. The center of the area where the majority of mining will occur lies in: COUNTY: ~4-c~ 7,•,s ~ /6th (Colorado) 10th (New Mexico) Ute PRINCIPLE FfE~IA c ecc one TOWNSHIP (write number and check direction): T 3 _ North ~ South RANGE (write number and check direction): East x West R ~ SECTION (write number): _ S 3 QUARTER SECTION (check one): ~~ NW SE SW QUARTER/QUARTER SECTION (check one): _ NE _ NW _ SE ~ SW GENERAL DESCRIPTION' (miles and direction /Z ///. C`s sr .} l/zp1 Sn„iH o F 13A~-~~'~~ from nearest town and approximate elevation) 5;~~0 * If the operator is a unit of State or county government, an application fee is not required. A fraction of an acre must be counted as one acre for fee calculation.