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// STATE OF COLORADO <br />DIVISION OF MINERAL•S`A'ND GEOLOGY ~'=' <~'~® <br />Department of Natural Relsources <br />t "sne anst.,RO9mits ~ II COLORADOi <br />r, C 1o7~ad~o~80203 ~~~~ O, ~oo~ D I V I S I O N O F <br />"-"P(ione: (303) 866-3567 MIN &RA L S <br />gnx: (303) e32~to6 ~ ~,:,~,> ct 4~..,. _:.~~ ~ Seolnptl G E O L O G Y <br />LIMITED IMPACT OPERATION (110(2)) RE SAfETYKCIENCENC <br />RECLAMATION PERMIT <br />~,y~~~~ ~~ /~ Bill Owens <br />` R-~' X-I ~HL°~ CJ~, APPLICATION FORM Go~emor <br />Russell George <br />Executive Director <br />Ronald W. Cattany <br />t'F1RCK tINR; New Application (Rule 1.4) Conversion Application (Rule 1.11) Division Director <br />Natural Resource Trustee <br />Permit # M-~,~-_~- (provide for conversions of existing permits) <br />The application for a Limited Impact Designated Mining Operation Reclamation Permit contains three major parts: (1) the <br />application form; (Z) Exhibits A-J, any required sections of Exhibit S and t reatecbnical Stability Exhibit, as reglritrd by the Office, <br />and outlined in Rules 6.1, 6.2, 6.3, 6.4.19 and 6.5; and (3) the application fee. When you submit your application, be sure to include <br />one (I) S~enrd and nnrari>rd original and one (1) copy of the application form, two (2) copies of Exhibits A-J, appropriate sections of <br />6.4.19 Exhibit S and 6.5 (Geotechnital Stability Exhibit), as required, and a check for the application fee described tinder (4) below. <br />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" X 14" size. To expedite <br />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 informat <br />i <br />on descri <br />bed <br />below <br /> <br />1. <br />Apnli A1 <br />l <br />0 <br />rant/nnerafnr nr cnntpanX name (name to he naeEl nn the pernritlt Nlh~ F- i 1r. , 0 (~ <br />~ <br />0idk'Ct! V ~r ~ <br /> <br /> 1.1 Type of organvation (corporation, partnership, etc.): ~ ~ 1T@f~ Ltn " r a `r~1-- ~O^~ <br /> 1.2 I.RS.TaxIDNo.: <br />2. Onera tinn name (pj mine nr aite namely l .At°o~ -1anID l~t~ ~ ~tn lC ~Q~."~ <br /> <br />3. Perml MPd ArreA~(new nr eYicti(~ Qltel' /E. <br />, <br />nn ~ T~~ ! ~, ~~ <br />~ <br />Y <br />~ <br />~~ <br />W ~ permitted aCre$ <br />4. ~: ( <br />~ <br />ST <br />L~~J <br />` <br />a .83 <br />D <br />P <br /> 4.1 New Application t:R75 nn application fee <br /> 4.2 Conversion Fee (from 110d to 110(2), (Rule 1.11.2(2)) J1FOT ~ /Od <br />~"'~ -yr.al~~- conversion fee <br />5. Prima ry rnmmndkie(~ to he minwlt ~"7~L.~ AtJlJ ~( [-,.l e~e~ <br /> <br />(), Name of mVner to the aErfare n( affected Iand' ~~n Cl~l-r~JL~" - `~ " '~l~Ti~-L; ~11~ <br />- <br /> <br />7. <br />Name ~ <br />^-~ <br />of owner to the srhanrrare ri~htc of affected lands ~ _ S~~ ~Xt~57)1~I' IQY,/1 !f'LW <br />$. one rd' minin4n~neratinns Surface ~ Underground In-Situ <br />Office of Office of Colorado <br />Mined Land Reclamation Active and Inactive Mines ~ "Geological Survey <br />