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1 � I <br /> 5TATE OF COLORADO <br /> DIVISION OF MINERALS AND GEOLOGY <br /> Depa1113 Shent rman <br /> ST.. Rol Resources 11�� C 0 <br /> 1 3 Shermz n 51.. Room 215 fl E 1'E I 1 �r''J <br /> Dc•nvc,.ColorzAo 80203 <br /> Phone:13031 866-3567 <br /> FAX:13031832-8106 FFB 12 1997 <br /> DEPARTMENT OF <br /> NATURAL <br /> CONSTRUCTION MATERIAISivicion of t.,�neraic�. RESOURCES <br /> REGULAR OPERATION (112) <br /> Romer <br /> RECLAMATION PERMIT APPLICATION FORM Foy <br /> Governmoro, <br /> lames S.Lochhead <br /> F.ecuil,e Drteaor <br /> 1t. <br /> Michael B.LorLg <br /> D.,oioo D,recror <br /> CHECK ONE: New Application (Rule 1.4.5) _ Amendment Application (Rule 1.10) <br /> Conversion Application (Rule 1. 11) <br /> Permit 0 _M -_ Q— h - C4 (provide for Amendments and Conversions of <br /> existing permits) <br /> The application for a. Regular 112 Operation Reclamation Permit contains three major parts: (1) <br /> the application form; (2) Exhibits A-S, Addendum 1, any sections of Exhibit 6.5 (Geotechnical <br /> Stability Exhibit; and (3) the application fee. When you submit your application, be sure to <br /> include one (1) complete signed and notarized IVORY ORIGINAL and four (4) copies of the completed <br /> ivory application form, -five (5) copies of Exhibits A-S, Addendum 1, appropriate sections of 6.5 <br /> (Geotech y Exhibit, and a check for the application fee described under Section (4) <br /> below. Exhibits should not be bound or in a 3-ring binder; maps should be folded to 8 1/2" X 11" <br /> r 4 1/2" X 14" size. To expedite processing, please provide the information in the format and <br /> L .ar described in this form. <br /> GENERAL OPERATION INFORMATION <br /> Type or print clearly in the space provided the information requested below. <br /> 1. Applicant/operator or company name (name to be used on permit) : <br /> 1.1 Type of organization (corporation,. partnership, etc. ) : x✓",rEr-J <br /> 1.2 I.R.S. Tax I.D. No. or Social Securityr Number: .Jr�/- ys "SS,;Z <br /> h 2. Operation name (pit, mine or site name) : oc CflrA)YOA) ( L)UA121ZV <br /> 3. Permitted acreage (new or existing site) 3, 6 permitted acres <br /> 3.1 Change in acreage (+ or -) �� 1G3� (vim acres <br /> 3.2 Total acreage in Permit area �'-ls •_� � acres <br /> 4. Fees: <br /> 4.1 New Application $1,875.00 application fee <br /> 4.2 New Quarry Application $2,325.00 quarry application <br /> 4.3 Milling Application (Non-DMO) S3.100.00 milling application <br /> 4.4 Amendment Fee $11550.00 amendment fee <br /> 4.5 Conversion to 112 operation (set by statute) S1,875.00 conversion fee <br /> S. Primary commoditie(s) to be mined: G � T va <br /> SH,✓� <br /> 5.1 Incidental commoditie(s) to be mined: 1. lbs/Tons/vr <br /> 2. teA)K/VOGOAJ Nn;J/A7cWAI lbs/Tons/vr 3. / lbs/Tons/yr <br /> 4. / lbs/Tons/vr S. / lbs/Tons/vr <br /> 5.2 Anticipated end use of primary commoditie(s) to be mined: Cc SSl��tc,Ton/ <br /> 5.3 Anticipated end use of incidental commoditie(s) to be mined: (Ifo l2.0 0VvU <br />