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<br />_ Q~~3~~ <br />CCT ? 1 1987 <br />LIMITED IMPACT OPERATION (110) <br />APPLICATION FORM <br />.....:~; I ~'.''t' <br />This form contains two major parts: (1) General Operation Information and (2) Exhibits <br />A-G. When you submit your application, be sure to include two si ned copies of the <br />General Operation Information, two copies of Exhibits A-G, and a~k for the <br />application fee described under (4) below. To expedite processing, please provide the <br />information in the format and order described in this form. _~ /_ f~~ __ ~~ ~4_~'1~ __ <br />575. ~t~ <br />- GENERAL OPERATION INFORMATION <br />Type or print clearly, in the space provided, all information described below. <br />1. Applicant/Operator Name: ~ Q,j r P l^( ~ w r- s T I~ o F ~ <br />2. Operation Name (Pit, mine or site name): ~ ~ S`r'/^/0 F F ~~ -~ M S , <br />3. Application type: Limited Impact Operation (110). F / ~ ~ <br /> <br />t~ 4. Application Fee for Permitted Acreage* <br />(E10 x (affected acres) + E25.00).* <br />Note permitted acreage and application fee and <br />attach a check for this amount when you file. <br />5. Substance(s) to be mined (e. g., gold/silver/gravel) <br />6. Owners(s) of Substance to be Mined <br />(check applicable box(s)): 1~1 Private <br />7. Owner(s) of Record of Affected Land <br />~_permitted acres. <br />O~ <br />7 ~; application fee. <br />r-1 ~ w ~' <br />^ State ^ Federal ^ Indian <br />(check applicable box(s)): ~ Private ^ State ^ Federal ^ Indian <br />8. Type of Mining Operation <br />(check applicable box(s)): ~ Surface ^ Underground ^ In-situ <br />9. Location Information. The center of the area where the majority of mining will <br />occur lies in: <br />COUNTY: O>7 0 R ~' A YtJ <br />PRINCIPLE MERID AN chec one •~ 6th (Colorado) ^ 10th (New Mexico)^ Ute <br />TOWNSHIP (write number and check irection): T ® IJorth ^ South <br />RANGE (write number and check direction): R ^ East Jt~ West <br />SECTION (write number): S <br />QUARTER SECTION (check one): ^ ^ NW SE ^ SW <br />QUARTERlQUARTER SECTION (check one): ^ NE ^ NW SE ^ SW <br />GENERAL DESCRIPTION: <br />(miles and direction ~~ M 1 ~f 5 SoUT ~J ~'~" / rt11• ~~~ <br />from nearest town and <br />approximate elevation) V~ G/ 16 G ! n- S Cr. D . ~} 7 0 ~3 f T - <br />* If the operator is a unit of State or county government, an application fee is not <br />required. A fraction of an acre must be counted as one acre for fee calculation. <br />