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STATE OF COLORADO <br />DIVISION OF MINERALS AND <br />Department of Natural Resources GEOLOGY <br />1313 Sherman St., Room 215 C O L D RA D O <br />Denver, Colorado 80203 CONSTRUCTION MATERIALS DIVISION O F <br />M I N ERA L S <br />Phone: (303) 866-3567 <br />fAX: (303) 832-8106 REGULAR (1 i2) OPERATION G E O L O G Y <br /> RECLAMATION PERMIT APPLICATION FORM A E uAnAno N• n I N I N c <br /> SAFETY•SCIENCE <br />CHECK ONE: ~ There is a File Number Already Assigned to this Operation <br />Permit # M - gs - B~'-_ (Please reference the file number current)}' assigned to [his operation) <br />New Application (Rule 1.4.5) <br />~ Amendment Application (Rule 1.10) <br />Bill Owens <br />Governor <br />Greg E. Walther <br />Enecutive Director <br />Ronald W. Caaany <br />Converoion Application (Rule l .l 1) Division Director <br />Natural Resource Trustee <br />Permit # M -~SJ - ©02 -_ (provide for Amendments and Conversions of existing permits) <br />The application for a Construction Materials Regular 112 Operation Reclamation Petmit contains three major parts: (1) [he application form; <br />(2) Exhibits A-S, Addendum 1, any sections ofExhibit 6.5 (Geotechnical Stabiliy F,xhibit; and (3) the application fee. When you submit your <br />application, be sure to include one (1) complete simed and notarized IV ORY ORIGINAL and one (I) copy ofthe completed I~ application <br />form, hvo (2) copies of Exhibits A-S, Addendum 1, appropriate sections of 6.5 (Geotechnical Stability Exhibit, and a check for the application <br />fee described under Sec4on (4) below. Exhibits should NOT be bound or in a 3-ring binder, maps should be folded to 81/2" X 11"or 81/2" X <br />14" size. To expedite processing, please provide the information m the format and order described in this form. <br />GENERAL OPERATION INFORMATION <br />Type or print ckady, in the space provided, ALL information requested bebw. <br />I. Applirantlonerator or rnmoanvname (name to be used on cermitl: k HJCB11'Ltk~'y F.S t9s tlJES5 ~/1c.~S~ <br />1.1 Type of organization (corporation, partnership, etc.): TC1 UST <br />l.2 I.R.S. Tax I.D. No. or Social Secttrity Number: 'f2-~6 ~3~q <br />2. Operation name (nit, mine or site name): <br />3. Permitted acreage (new or eaistine site): <br />3.1 Change in acreage (+) <br />3.2 Total acreage in Permit area <br />4. Fees: <br />4.1 New Application <br />4.2 New Quarry Application <br />4.4 Amendment Fee <br />4.5 Conversion to 112 operation (se[ by statute) <br />perratined acres <br />acres <br />02/6 l acres <br />$2.344.00 application fee <br />$2.906.00 quam' application <br />$1.938.00 amendment fee <br />$2.344.00 conversion fee <br />5. Primary commoditie(s) to be mined: (>phA ~ftiNd ~ IPRV2=L. <br />5.1 Incidental commoditie(s) to be trained: 1. - Ibs/Tons/vr 2. / lbs/I'ons/vr <br />3. / lbs(Tons/vr 4. / lbs/TonshT 5. / Ibs/Tonsh-r <br />5.2 Anticipated end use of primary wmmoditie(s) to be mined: ~9Ot-0 ~!) P~2B° (oVs /I'~TR~S' m~K~T <br />5.3 Anticipated end use of incidental wmmoditie(s) to be mined: ~~sJ~ ~ ~D R'~~ ~~ QAI~ R ~S~ <br />Office of Office of Colorado <br />Mined Land Reclamation Active and Inactive Mines Geological Survey <br />