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STATE OF COLORADO <br />DIVISION OF MINERALS AND GEOLOGY <br />Department of Natural Resource] <br />1313 Silennan St, Room 215 <br />Oerlver, Colorado 80203 <br />Phone: (303) Br>rt3567 CONSTRIICTION MATERIALS <br />FA%: (303) 832A10ti REGULAR (112) OPERATION <br />RECLAMATION PERMIT APPLICATION FORM <br />claECx oNE: There ~ a h?De Nnmber A13sady Assigned to this Operathou <br />Permit ~ ,,,~_'_'_-_ (Please reference tlu file number clarenlly assigned to this operation) <br />_ New Application (Rule 1.4.5) _ Amwdmeat Application (Rule 1.10) <br />C•OnVtr710n AppLCetim (Ruk j.l 1) <br />Permit # ~_'~ -~ (ptOVlde fOr Ameadmenta and ConversMns of gD91>dg permits) <br />RADO <br />ON OF <br />RALS <br />GEOLOGY <br />RI CLANATION•MININO <br />]AgTT•3CI]N C] <br />alit Owau <br />r~iOTlrllOr <br />Rufsell George <br />FxecWve DIrL•mor <br />RonaM W. cmaay <br />DNisbn Director <br />Natural Re]oulce 7mstee <br />The epplicatian for a Construction Materials Regular 112 Operation Reclamatim Permit swntains three majsxparts: (1) the applicatiaD form; <br />(2) Exhibits A-S, Addendtmt 1, ffiy sodi~s ofEx6tbit 6.5 ((iaatechuical Stability E>~ibit; and (3) the applicaGOn fee. Wheayou submityotr <br />application, be sure to include one (1),r~plete gjgped and notarised ORIGINAL and one (1) oopyofthe completed applicaRCnSoFm, two (2) <br />copies ofl3dubits A-S, Addendtmi 1, appropriate sections of6.5 (Gootx3uical Stability F.xhtbit, and a chockfor the applicatice fee described <br />under Section (4) below. Exhibits should~VO~ be bound sx iD a 3-ringbinder; maps should befolded to 8 1/2" X 11" ar81 /l' X 14"size To <br />~u P~a+~B. Please provide the information in the format and rider described is this form. <br />GENII2AL OPERATION INFORMATION <br />Type or prhat clearly, is the epam provided, ALI l~ormatbn requested below. <br />1. Aaptlcant/ocerator or comnsnvname (name to be used on ceraitfl: <br />1.1 Type of sxganizatioo (corporatism, Partnership. etc.): <br />2. Oceratioa name (nit. mine or site name): <br />3. Permkted acreage (new or esistlna site): <br />3.1 Change in arrange (+) <br />3.2 Total aasage in Permit area <br />4. ~: <br />4.1 New Application <br />4.2 Ncw Quatiy Application <br />4.4 A~ndmmt Fee <br />4,5 Cowasism to 112 operation (set by statute) <br />permitted acrev <br />a~ <br />52.344.00 application fee <br />52.906.00 gamry application <br />51.938.00 ameadmentfee <br />52.344.00 sxxiversioD fee <br />5. Prlmarv commoditie(s) tb be mintd: <br />s.1 Incidental commoaitie(a> ~ be mined: 1. mslfrms/vr <br />3. / lbs/fons/vr 4. / Ibs/I'ons/vr <br />5.2 Anticipated end use of primary Lxsnmoditie(s) to be mined: <br />5.3 Anticipated end use of incidental commoditie(s) to be minesi: <br />2. / Ibs/Tonalvr <br />5. / lbs/fons/vr <br />OBtce of Office of Colorado <br />Mined Land ReclanWitm Active and Inactive Mines riMl(WIftI SI,NPV <br />