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ECEIVED <br />'u"' ° 23TAI-E OF COLORADO <br />DIVISION OF MINERALS AND GEOLOG IYISIan of Minerals and Geology <br />Department of Natural Resources ~~ <br />131 3 Sherman St., Room 21 S ' <br />Denver, Colorado 60203 <br />Phone: (3031 866-3567 CONSTRUCTION MATERIALS <br />FAx: (3D3) s3z-alo6 REGULAR (112) OPERATION <br />RECLAMATION PERMTT APPLICATION FORM <br />CHECK ONE: There is a File Number Already Assigned to this Operation <br />Permit # M -_ _ - (Please reference the file number currently assigned to this operation) <br />New Appbca[ion (Rule L4.5) )C Amendment Appbcation (Rule L 10) <br />Conversion Application (Rule 1.11) <br />Petmit # M -Z-~-_ (provide for Amendments and Conversions of e:cisting permits) <br />DIVISION O <br />MINERAL <br />& <br />GEOLOG <br />R ECIAMATIO' <br />MI NING•SAFET <br />Bill Owens <br />Governor <br />Gre6 E. Walther <br />Executive Director <br />Michael e. Long <br />Division Director <br />The application for a Construction Materials Regulaz 112 Operation Reclamation Permit contains three major parts: (1) the application form; <br />(2) Exhibits A-S, Addendum 1, any sections of Exhibit 6.5 (Geotechnical Stability Exhibit; and (3) the apphcation fee. When you submit your <br />application, be sure to include one (1) complete si>med and notarized NORY ORIGINAL and four (4) copies of the completed Ivory <br />application form, five (5) copies of Exhibits A-S, Addendum 1, appropriate sections of 65 (Cxotechnical Stability Exhibit, and a check for <br />the apphcation Fee described under Section (4) below. Exhibits should NOT be bound or in a 3-ring binder; maps should be folded to <br />8 1/2" X 11" or 8 1/2" X 14" size. To expedite processing, please provide the information in the format and order described in this form. <br />GENERAL OPERATION INFORMATION <br />Type or print clearly, in the space provided, all information described below. <br />I. Applicant/ooerator or comoanv name (name to be used on permit): <br />0/rJcos {/e Sn/ Goo/r~ %c. d6o //~. ~«/ ~o.~~.c~ a~ /Y/csg coffin {„ <br />1.1 Type of organization (corporation, partnership, etc.): (bI'~71YO ~iorl <br />1.2 I.RS. Tax I.D. No. or Social Security Number: <br />2. Operation name (pit, mine or site name): <br />3. Permitted acreaae (new or eaisiine site): <br />3.1 Chaage in acreage (+) <br />3.2 Total acreage in Pemtit area <br />4. Fees: <br />4.1 New Application <br />4.2 New Quarry Application <br />4.4 Amendment Fee <br />4S Conversion to 112 operation (set by statute) <br />~. Primary commoditie(s) to be mined: ~_ G~'A/e/ <br />42.7s~ permitted acres <br />4iR.4(o acres <br />9/. Z ~ acres <br />$2,344.00 application fee <br />$2 906.00 quam application <br />,938.0 amendment fee <br />$2.344.00 conversion fee <br />~.1 Incidental commoditie(s) to be [Wined: L / Ibs/Tons/vr 2. / lbs/Tons/vr 3. / lbs(fons/vr <br />4. / Ibs/Tons/vr i. / Ibs/fons/vr <br />5.2 Anticipated end use of primary commoditie(s) to be mined: ~pac/ ~las~'-J ~SO~is/f <br />5.3 Anticipated end we of incidental commoditie(s) to be mined: <br />