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DIVISION OF MINERALS AND GEOLOGY <br />Department of Natural Resources <br />1313 Sherman St., Room 215 <br />Denver, Colorado 80203 <br />Phone: (303) 866-3>6i <br />FP,?,: (303) 832-8 i 06 <br />i~~~ f" U <br />STATE <br />. ~N~:. <br />YVl-2ao4 - 00 I <br />COLORADO <br />.IAN i 4 2004 <br />DIVISION OF <br />CONSTRUCTTOn"1)9A~Eti~Il~~sandGeology M I N BRA L S <br />~~~~~~~ G E O L O G Y <br />~' ~~~ ~ ~J ~~ LIMITED IIYIPACT (110) OPERATION R E C L A M A T I O N <br />JAN 0 ~ 2004 MINING•SAFETY <br />~~~ ~~~~'~ CLAMATION PERMIT APPLICATION FORM <br />Bill Owens <br />Division of Minerals and GeoIQ$yemor <br />Greg E. Vlalcher <br />CIS C1~ Oiv'E: Them is a File Number Already Assigned to this Operation Exe<urive Director <br />ftona(d W. Cattany <br />Permit # M -` -` (Please reference the file number currently assi°aed to this operation) Acting Division Director <br />__g_ New Application (Rule ].4.5) Amendment Application (Rule 1.10) <br />Conversion Application (Rule 1.71) <br />Permit # M - (provide for Amendments and Conversions of existing perrltits) <br />The application for a Construction Materials Limited Impact (110) Operation Reclamation Permit contains three major parts: (1) the <br />application form; (2) Exhibits A-J, Exhrbit L, Addendum 1, any sections of Exhibit 6.5 and Geotechnical Stability Exhibit, as required by the <br />Office, and outlined in Rules 6.1, 6.2, 6.3, 6.5, and 1.6.2(1)(b); aad (3) the application fee. When you submit your application, be sure to <br />include one (1) complete signed and notarized IVORY ORIGINAL and one (i) copy of the completed Ivy application form, two (2) copies <br />of Exhibits A-J, Exhibit L, Addendum 1, and appropriate sections of 6.5 (Geotechnical Stability Exhibit), as required, and a check for the <br />application fee described under (4) below. Exhibits should NOT be bound or in a 3-ring biadcr; maps should be folded to 8 i/2" X 11" or <br />8 1/2" X 14" size. To expedite processing, please provide the information in the format and order described in this form. <br />GENERAL OPERATION INFORMATION <br />Type or print clearly, in the space provided, ALL information described below. <br />1. <br />2. <br />3. <br />licaut/operator or_comoauY name. (name to be used on Hermit): L i nco 1 n Coun t <br />1.1 Type of organization (corporation, partnership, etc.): Government <br />1.2 LRS.TaxIDNo.orSocialSecurityNumber:2.: 84-6000-781 <br />Lofdahl <br />Operation name (nit, mine or site Hamel: <br />Permitted acreaee (new or eaistina site): <br />3.1 Change in acreage (+) <br />Q - 6 permitted acres <br />acres <br />3.2 Total Acreage in Permit Area <br />4. Fees: <br />4.1 New Application: <br />Amendment Fee (C.RS. 34-32.5-125(II)): <br />4.2 Conversion Fee (from 110d to 110 $875.00 conversion fee (Rule 1.11.2(2)) <br />5. Primary rnmmoditie(s) to be mined: 9 a n d Grave t <br />9 . Fi acres <br />$],094.00 application fee <br />$719.00 application fee <br />5.1 Incidental commoditie(s) to be mined: 1. NA/ Ibs/Tons/vr 2. / lbs/Tons/vr 3. / lbs/Tons/vr <br />4. / Ibs/Tons/vr 5. / Ibs/Tons/vr <br />5.2 Anticipated end use of primary commoditie(s) to be mined: Road M a i n t e n an c e <br />Anticipated end use of incidental commoditie(s) to be mined: <br />