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<br />STATE OF COLORADO <br />DIVISION OF MINERALS AND GEOLOGY <br />Deparmnent of Natural Resources <br />7313 Sherman St., Room 215 <br />Denver, Colorado 80203 <br />Phone: (303) 8663567 <br />FAx: (303) 832$106 <br />LD1ITfED IlIIPACT OPERATION (110(2)) <br />RECLAMATION PERMIT <br />1^ AP/P~L~I/CaATION FOR(,~M n~ <br />" t for lTola ~~Sli. IC'~V'wi r {"C o trx~ Ye~u~~ <br />('uF[`K nTaF: New Application (Rule 1.4) <br />Permit # <br />Conversion Application (Rote 1.11) <br />(provide for conversions of existing permits) <br />COLORADO <br />DIVISION O F <br />MINFr,R <br />GEOLOGY <br />RECLAN~TION•NI NING <br />S~FETT•LCIENCE <br />Bill Owens <br />Governor <br />Russell George <br />Executive Direcmr <br />Ronald W. Canany <br />Division DIRCIOf <br />Natural Resource Trustee <br />The application for a Limited Impact Designated Mining Operation Reclamation Permit contains three major parts: (i) the <br />appligtion form; (2) Exhibits A-J, any required sections of Exhibit S and Geoteclurical Stability Exhibit, as required by the Office, <br />and outlined in Rules 6.1, 6.2, 6.3, 6.4.19 and 6.5; and (3) the application fee. When you submit your application, be sure to include <br />one (1) "~ efl and nnrari~sl original and one (1) cePy of the application form, two (2) copies of Exhibits A-J, appropriate sections of <br />6.4.19 Exhibit S and 6.5 (Geotecltnical Stability Exhibit), as required, and a check for the application fee described under (4) below. <br />Exhibits should not be bound or in a 3-ring binder; maps should be folded to 8 1/2" X 11" or 8 1/2" X 14" size. To expedite <br />processing, please provide the information in the format and order described in this form. <br />GENERAL OPERATION INFORMATION <br />Type or print clearly, to the space provided, all information described below <br />I. Applirstntl~erntnr nr rnpipany name [name to M nwl nn fhP ~FwrmiFl• <br />1.1 Type of organization (corporation, partnership, etc J: <br />1.2 I.RS. Tax ID No.: <br />2, (lneratinn name (~ mina nr Hite namele <br />3. PPF'FEEittPd arRa~nPw nr PStsAing ti~~ <br />4. Fres: <br />4.1 New Application <br />4.2 Conversion Fee (from 1104 to 110(2), (Rule 1.11.2(2)) <br />5, 1Prima ^rnmmnditiP'aw fn rEP minPds <br />6. <br />7. <br />$, '~pr rsf mininv~nrsPrstinns ~ $))tface <br />Underground In-Sttu <br />7 • / permitted acres <br />application fee <br />conversion fee <br />Office of Office of Colorado <br />Mined Land Reclamation Active and Inactive Mines Geological Survey <br />