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TATE OF COLORADO <br />DIVISION OF MINERALS AND GEOLOGY <br />Deparbrtent of Natural Resources <br />1313 Sherman St, Roan 215 C O L D RA D O <br />Denver, Colorado 80203 DIVISION O F <br />Phone: (303) 866-3567 M I N E <br />RA L S <br /> ~ <br />FAX: (303) 832-8106 G E O L O G Y <br /> LIMITED IMPACT OPERATION /110(2 <br />\ N RECLANATION•NINING <br />SAFETY•SCIENCE <br /> RECLAMATION PERMIT <br /> Bill Owens <br /> APPLICATION FORM eovemor <br /> Russell George <br /> ERecutive DirecTOr <br /> Ronald W. Cattany <br />Cl-fFCx nNF; New Application (Ruk 1.4) Conversion Application (Rule 1.11) Division Dimdor <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 />appliption form; (2) Exhibits A-J, a~ required sections of Exhibit S and Geotechnical Stability Exhibit, as required 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 (1) signedand_noiariur~ original and one (1) copy of the appliption forn/, two (2) copies ofExhibits A J, appropriate sections of <br />6.4.19 Exhibit S and 6.5 (Geotechnical Stability Exhibit), as required, and a check for the application fee described lender (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 information described below <br />1. <br />1.1 Type of organisation (corporation, partnership, etc.): <br />12 LRS. Tax ID No.: <br />2. Oneretinn name (1H1 mine nr Site nameL• <br />3, PPrmitfed aCM• A~1TP InP.w m' PYtFting AI~P~~ <br />4. F~g• <br />4.1 New Application <br />4.2 Conversion Fee (from 110d to 110(2), (Itu1e ]. <br />$, Primar^rnmmrulitie(,y~ to he minM~ <br />6. Name rrf mvner }n the ».rface of afferterl land <br />~~ permitted acres <br />application fee <br />conversion fee <br />8. ape nf' mininv~nrnarntinn: _~ Surface Underground In-Situ <br />Office of 0f6ce of ~ Colorado <br />Mined land Reclamation Active and InaRive Mines Geological Survey <br />