REV98918

• Permit No: M1981043
• IBM Index Class Name: Revision
• Doc Name: EXHIBIT H MUNICIPALITIES WITHIN A TWO MILE RADIUS EXHIBIT I PROOF OF FILING WITH CNTY CLERK EXHIBIT
• Type & Sequence: AM1
• Media Type: D
• Archive: No

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STATE •
OF COLORADO
DIVISION OF MINERALS AND GEOLOGY
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Depanmem of n
1 313 Sherman 51.. Room ? 15 Ir
Denver, Colorado 80?03
Phone: [phone] ~ 3567 E~
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CONSTRIICTION MATERIALS MI(3P,t3~5
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LIMITED IMPACT ( 110 ) OPERA ~
TION Roy Romer
Governor
R]iCLAMATION PERMIT AP?LIGATION FORM James 5. Lo<hhead
Etecmn, ~ueaor
Michael B Long
Division Director
CHECK ONE: C1Lr~i~irCCr~Yr.r..f.-r`ri.}} ~ Amendment Application (C.R.S. 34-32.5-110)
Permit 'k ~' -U%~ _ /)~%5 -_ (Tp r~ovide for Amendments and Conversions of
existing permiCS)
The application for a Construction Materials Limited Impact (110) Operation Reclamation Permit
contains three major parts: (1; the application form; (2) Exhibits A-J, Exhibit L,~Addendum 1,
any sections of Exhibit 6.5 and Geocechnical Stability Exhibit, as required by the Office, and
outlined in Rules 6.1, 6.2, 6.3, 5.5, and 1.6.2 (1)(b); and (3) the application fee. [9hen you
submit your application, be sure to include one (1) comolete'sianed and notarized IVORY ORIGINAL_
and one (1) copy of the complea ed Ivory application form, two (2) copies of Exhibits A-J
Exhibit L, Addendum 1, and appropriate sections of 6.5 (Geotechnical Stability Exhibit), as
required, and a check for the application fee described under (4) below. Exhibits should NOT ba
bound or in a 3-ring binder; meaps should be folded to 8 1/2" X 11" or 6 1/2" X 14" size. To
expedite processing, please prcvide the information in the format and order described in this
form.
GEPIERAL OPERATION INFORMATION
Type or print clearly, is the space provided, ALL information described below.
----------------- ------------------------------------------- -_
1. Applicant/operator or compazLy name (name to be used oa Hermit):
1.1 Type of organization (corporation, partnership, eUtc.~ : %.a---= ,o.r l.~o~~~t :.~-a
1.2 I.R.S. Tax ID No. or Social Security Number: CO `~ - /~~ !/c%/j `a
2. Operation name (pit, mine or site name): ;cr n~ i'~~'aG~c,_- Y-':~:-<~'

3. Permitted acreage (new or er:i stin4 site): /i ~~ permitted acres
3.1 Change in acreage (+ or -) ~ acres
Total Acreage in Permit Area .- S `~ acres

4. Fees:
4 .1 ee lset! ~!~r application fee
Amendment F ee (C.R.S. 34-32.5-12~(II)) 5575.00 application fee
4 .2 Conversion Fee (frog. li0d to 110 56"75.00 conver sion fee (Rule 1.11.2(2))

S . Primar y commoditie ( s ) to be mined: , O C K - 1.-+4°-~_<~_.i~
5. 1 Incidental commoditie(s) to be mined: 1. 1bs/Tons/•~:r
2. / lbs/Tons/vr 3. / lbs/Tons/vr
4. / 1bs/Tons/vr 5. 1bs/YOBS/vr
5. 2 Anticipated end use of primary commoditie(s) to be :Wined: err:=r~s/ ~ ~ ~c~!~'.!= ._~<
5. 3 Anticipated end use of incidental commoditie(s) to be mined: r°~- % ~ 'i
/L~o/