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TATE OF COLORP~DO <br />DIVISION OP MINERALS AND GEOLOGY <br />Department of Natural Resources <br />1313 Sherman St., Room 21 S <br />Denver, Colorado 80203 D 1 v 1 5 1 o N o r <br />Phone: (303) 866-3567 n'1 11``1 E Rf\ L $ <br />FAY:: (303) 832-&106 CONSTRliCTION MATERIALS & <br />GEOLOGY <br />LIMITED IMPACT (110) OPERATION R E C L A M A T I O N <br />N,ININ G•SAFETY <br />RECLAMATION PERMTT APPLICATION FORM <br />Bill Owens <br />Governor <br />Greg E N'alcher <br />C7_-LCF: ONE: There is a File Number Atread~~ Assigned to this Operatioa Execurive o+recmr <br />Ronald W. Cottony <br />Permit # M -_ _ _ (Please reference the file number currently assigned to this operation) Aging Division Director <br />X New Application (Rule 1.4.5) <br />Amendment Application (Rule 1.10) <br />Conversion .4pplica[ion (Rule 1.11) <br />Permit # M - (provide for Amendments and Conversions of existing permits) <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, Exhibit L, Addendum 1, any sections of Exbibit 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); and (3) the application fee. When you submit your application, be sure to <br />include one (1) complete siffied and notarized IVORY ORIGINAL and one (1) copy of the completed Iv1}~ application form, rivo (2) copies <br />of Exhibits A-J, Exhibit L, Addendum 1, and appropriate sections of 6.5 (Geotechnical Stability Exhibit), as requued, and a check for fhe <br />application fee described under{4) below. Exhibits should NOT be board ar in a 3-ring binder; maps shculd be fokled to 8 112" X I 1 " or <br />8 1/2" X 14" size. To expedite processing, please provide the information in the forma[ 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 />1.2 I.RS. Tax ID No. or Social Security Number: 2.: <br />A~plicaot/operator or company name (name to be used on permitl: L i ri C O 1 ri C Ourit <br />LI Type of organization (corporation,partaerslup,etcJ: Government <br /> <br />2. Operation name toil, mine or site namel: L o f d a h l <br />3. Permitted acreage (new or eaistin¢ site): <br />3.1 Change in acreage (+) <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 commoditie(s) to be mined: San d <br />Gravel <br />9 . 6 permitted acres <br />acres <br />9 .6 acres <br />$].094.00 application fee <br />$719.00 application fee <br />5.1 Incidental commoditie(s) to be mined: I. NA / Ibs/Tons/vr 2. / ]bs/1'otis/vr 3. / lbslTons/vr <br />4. / Ibs/Tons/vr 5. / ]bs/Tons/vr <br />5.2 Anticipated end use of priunary commoditie(s) to be mined: Road M a i n t e n a n c e <br />Anticipated end use of incidental commoditie(s) to be mined: NA <br />