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TATE OF COLORADO <br />DIVISION OF MINERALS AND GEOLOGY <br />Department of Natural Resources <br />1313 Sherman S[., Room 215 <br />Denver, Colorado 80203 <br />Phone: (309) 866-3567 <br />FAX: (303) 832-8106 <br />RECElVEp <br />JUN 0 4 2003 / <br />DIVISION O F <br />MINERALS <br />GEOLOGY <br />RECLAMATION <br />MINING•SA FETY <br />CONSTRUCTION MATEBIALS 9ryisian of Minerals and Geology <br />REGULAR (112) OPERATION <br />RECLAMATION PERMIT APPLICATION FORM <br />CHECK ONE: There is a Fr7e Number Already Assigned to tbis Operation <br />Permit # M -_ _ , (Please reference the Sle nmmber currently assigned to this operation) <br />New Application (Rule 1.4.5) ~ Amendment Application (Rule 1.10) <br />Convenion Applica oa (Rule 1.11) / <br />Permit # M -~~-~74- (provide for Amendments and Conversions of existing permits) <br />Bill Owens <br />Governor <br />Greg E. Walther <br />Executive Director <br />Ronald W. Cottony <br />Acting Division Director <br />The application for a Construction Materials Regldar 112 Operation Reclamation Permit contains three major parts: (1) the application form; <br />(2) Exhrbits A-S, Addendum ],any sections of Exbibit 65 (Geotechnical Stability Exhrbit and (3) the application fee. When you submit your <br />application, be sure to include one (1) commlete siffied and notarized IVORY ORIGINAL and one (1) copy of the completed III application <br />foim, two (2) copies ofExhibits A-S, Addendum 1, appropriate sections of 6.5 (Geotechidcal Stability Exhibit, and a check for the application <br />fee descnbed ender Section (4) below. 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" <br />X 14" size. To expedite processing, please provide the information in the format and order descnbed in this form. <br /> GENERAL OPERATION INFORMATION <br />Type or print clearly, in the space provided, ALL information requested below. <br /> L ~ <br />J <br />1. Ao olicantlooerator or comnanv name (name to be used on cermitY <br />A FA Q(, ~~ <br />,I <br />EST f <br />].1 Type of organization (corporation, Partnership, etc.): ~'OR D OR 'r/O Ar <br />1.2 I.RS. Tax I.D. No. or Social Security Number: a2 S - / 5 3179 ~~ <br />2. Op eration name (nit, mine or sfte name): ~ P L(' 1 F I CA-T /Lri/ ~4C~ ~~~S <br />3. PermitIIed acrea?re (new or eSlStino sixe): ,:1~,2/~'. ~. pz~itted a. res <br />3.1 Change in acreage (+) '~O r acres <br />3.2 Tnia' acrease'v-rPer~.:z,isea °~ acres <br />4. Fees <br />4.1 New Application $2.344A0 application fee <br />4.2 <br />4.4 New Quaff' Application <br />Amendment Fee $~ 906A0 quarry application <br />$1.938. amendtacatfez <br />4.5 Conversion to 112 operation (sei by statute) $2644.00 conversion fee <br />~. Primary commoditie(s) to be mined: ~Tn,~ii- <br />5.1 Incidental commoditie(s) to be mined: 1. /-~ FF - IbslTons(vr 2. / IbslTons/vT <br /> 3. / ]bs/Tons/vr 4. / lbslfons/vr 5. 1 1bsrTonshr. <br />5.2 Anticipated end use of primary coitunodiiie(s) to bz mined: ~ (7.11.5T(ZLLCT7D .cL RTE 2(l~-( <br />5.3 Anticipated end use of incidental commoditie(s) to be mined: '~f) <br />