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TATE OF COLORADO <br />DIVISION OF MINERALS AND GEOLOGY <br />Department of Natural Resources <br />1313 Sherman St., Room 215 C O L D RA D O <br />Denver, Colorado 80203 D I v 15 t O N o r <br />Phone: (303) 866-3567 MINERAL S <br />FAX: (303) 832.8106 G E O L O G Y <br />LIMITED IMPACT OPERATION (110(2)) 0.EC LANATION•MINING <br />sAFETY•SCIENCE <br />RECLAMATION PERMIT <br /> <br /> <br />j,. <br />A <br />~ <br />APPLICATION FORM <br />~ <br />~ <br />~ Bill Owens <br />Governor <br />Russell George <br />f4tB1w•(~ ylAp~~.1j ' <br />pr <br />CHRCx nxp: New Application (Rule 1.4) O <br />~U~ <br />Gp(~ ~o-Slrr 1 ~YYN I <br />Conversion Application (Rule 1.11) Executive Director <br />Ronald W. Cattany <br />Division Director <br /> Natural Resource Trustee <br />Permit # M- (provide for conversions of existing permits) <br />The application for a Limited Impact Designated Mining Operation Reclamation Permit contains three major parts: (I) the <br />application form; (2) Exhibits A-J, any required sections of Exhibit S and l;eotcehnical Stability Exhibit, as required by the Office, <br />and outlined in Rules 6.1, 6.2, 63, 6.4.19 and 6.5; and (3) the application fee. When you submit your application, be sure to include <br />one (1) ci9 rA and nnfari,etl original and one (1) copy of the appligtion form, two (2) copies of Exhibits A-J, appropriate scetions of <br />6.4.19 Exhibit S and 6.5 (Geotechnical Stability Exhibit), as required, and a cluxk for the application fee described under (4) below. <br />Exlubits should not be bound or in a 3-ring binder; maps should be folded to 8 I/2" X Il" or 8 1/2" X 14" size. To expedite <br />processing, please provide t1Le information in the format and order described in tlis form. <br />GENERAL OPERATION INFORMATION <br />Type or print clearly, hn the space pro~~ded, all information described below <br />1. AA~nlicant~/ peratnr nr rnm=nanv name !name fn he noes! nn the ~_tl~ <br />1.1 Type of organization (corporation, partnership, etcJ: <br />1.2 I.RS. Tax ID No.: <br />2. Aneratinn name (~ mine nr ails namelc <br />3. Permitted arre~ae (new nr rsiafin~aitgl~ <br />4. Frty: <br />4.1 New Application <br />4.2 Conversion Fee (from 110d to 110(2), (Rule 1.11.2(2)) <br />5, Primary rnmmnditie(~ to he mintvls <br />6. Name of mvner to the ~Erfare of affected lands <br />7. Name EFf owner to the nEhal,rface risahts cif affected land <br />$, ',(~pe of minin~,nrwratinn~ Surface Undergrotmd <br />In-situ <br />permitted acres <br />[R'75 On appliption fee <br />SR75 fNr conversion fee <br />Office of Office of Colorado <br />Mined Land Reclamation Active and Inactive Mines Geological Survey <br />