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II�'lllll"II III <br /> RECEIVED <br /> LIMITED IMPACT OPERATION (110(2) ) <br /> RECLAMATION PERMIT Jul, ' A Mfli <br /> APPLICATION FORM <br /> Mint: <br /> The application for a Limited Impact Operation Reclamation Permit contJ0GlBriiatlira1ma Qn01 <br /> parts: (1 ) the application form; (2) Exhibits A-J; and, (3) the application fee. When <br /> you submit your application, be sure to include two (2) signed originals of the <br /> application form, two (2) copies of Exhibits A-J , and a ccFecct—for the application fee <br /> described under (3) below. To expedite processing, please provide the information in <br /> the format and order described in this form. Q _ ?1 41 PL45so'(D Yo 7 _ Xl,;)5 a - <br /> GENERAL OPERATION INFORMATION <br /> Type or print clearly, in the space provided, all information described below. <br /> 1 . App r name: S <br /> 1 .1 Type of organization (corporation, partnership, etc.): <br /> 2. Operation name (pit, mine or site name) : iv 7- <br /> 2.1 I.R.S. Tax ID No. or Social Security No.: 15_'J '2 <br /> 3. Application fee for permitted acreage* Z permitted acres• <br /> ($25. .00 + 10/acre)* ° <br /> Note permitted acreage and application fee and �` �� <br /> attach a check for this amount when you file. application fee <br /> 4. SubstanCEI(s) to be mined (e.g., gravel/gold/borrow) : <br /> 5. Name of owner of .surface of affected land: <br /> 6 . Name of owner of subsurface rights of affected land: /,Yf.4n4lnnir. Q eE'�/NC� <br /> 7. Type of mining operation: LC Surface _ Underground _ In-situ l <br /> 8. Location information. The center of the area where the majority of mining will <br /> occur lies in: <br /> COUNTY: <br /> PRINCIPAL MERIDIAN (check one): 6th (Colorado) 1Oth (New Mexico) Ute <br /> TOWNSHIP (write number and check direction): T JJV_ North k—South <br /> RANGE (write number and check direction): R #Ljj _ East West <br /> SECTION (write number): S <br /> QUARTER SECTION (check one): �y/MNW SE SW <br /> QUARTER/QUARTER SECTION (check one): _ NE _ NW _ SE _ SW <br /> GENERAL DESCRIPTION: <br /> (miles and direction 11 1 ' Wei oF- iA re-7 4T,-9_Q <br /> from nearest town and <br /> approximate elevation) �64f7 <br /> * A fraction of an acre nest be counted as one acre for fee calculation. If the <br /> operator is a unit of state or county government, an application fee is not required. <br /> I <br />