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III IIIIIIIIIIIII III 999 LIMITED IMPACT OPERATION (110) APPLICATION FORM ~ RECEIVED FEB 191987 MINED LAND RECLAMATfON f?IVISION This form contains two major parts: (1) General Operation Information and (2) Exhibits A-G. When you submit your application, be sure to include two ~s~~i nam~ed copies of the General Operation Information, two copies of Exhibits A-G, and as c~~c for the application fee described under (4) below. To expedite processing, please provide the information in the format and order described in this form. m_ ~- ~ sLi GENERAL OPERATION INFORMATION Type or print clearly, in the space provided, all information described below. 1. Applicant/Operator Name: ~~,~raa~ Q„a,.,-;pG_ T.,~ 2. Operation Name (Pit, mine or site name): sia~k obsidian 3. Application type: Limited Impact Operation (110). 4. Application Fee for Permitted Acreage* 9 permitted acres. (E10 x (affected acres) + E25.00).* Note permitted acreage and application fee and attach a check for this amount when you file, sirs.nn application fee. 5. Substance(s) to be mined (e. g., gold/silver/gravel): A,~~4 n,,~;~,;~„ 6. Owners(s) of Substance to be ldined (check applicable box(s)): fs~ Private ^ State ^ Federal ^ Indian 7. Owner(s) of Record of Affected Land (check applicable box(s)): ® 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 1n: COUNTY: Custer PRINCIPLE MERIDIAN c ec one ~ ^ 6th (Colorado) ^ 10th (New Mexico)^ Ute TOWNSHIP (write number and check direction): T zz ^ North ® South RANGE (write number and check direction): R i~ p East g West SECTION (write number): S i6 QUARTER SECTION (check one): ^~~ ® NW ^ SE ^ SW QUARTER/QUARTER SECTION (check one): ^ NE ^ NW ® SE ^ SW ~ GENERAL DESCRIPTION: (miles and direction 11n.;P, m;,P Nn rth Silvnrr lif fo rn __ from nearest town and approximate elevation) ~;p„a*;~„ a nn n * 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.