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TATE OF COLORADO <br />DIVISION OF MINERALS AND GEOLOGY <br />Drpartment of N.riural Resources <br />I'S I.S Sherman St., Room ?15 <br />Dunvcr, Grlorado FlOd07 D 1 v I S S O N O F <br />Pnonc: rsosl uhh-~st,> MINERAL S <br />r-,~x I ~sn tl a s z-x I D~ ~ <br />GEOLOGY <br />CONSTRUCTION MATERIALS n iN i N cMSn~F E~ "r <br />REGULAR (112) OPERATION <br />RECLAMATION PERMIT APPLICATION FORM Bill Owens <br />Governor <br />Greg E. Watcher <br />Executive Direcbr <br />ichael 8. Long <br />CHECK ONE: _ New Application (Rule 1.4.5) _ Amendment Application (Rule L10~';vsfon Dtrector <br />Conversion Application (Rule 1.1 l) <br />Permit tk M -_ _ _ (provide for Amendments and Conversions of existing permits) <br />The application for a Conswction Materials Regulaz 112 Operation Reclamation Permit contains three major parts: (l) the applicarion form; <br />(2) Exhibits A-S, Addendum 1, any sections of Exhibit 6.5 (Geotechnical Stability Exhibit, and (3) the application fee. When you submit your <br />application, be sure to include one (1) complete signed and notarized IVORY ORIGINAL and four (4) copies of the completed Ivy <br />application form, five (3) copies of Exhibits A-S, Addendum 1, appropriate sections of 6.5 (Geotechnical Stability Exhibit, and a check for <br />the application fee described under Section (4) below. Exhibits should NOT be bound or in a 3-ring binder; maps should be folded to <br />8 112" X 1 t" or 8 112" X 14" size. To expedite 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 mquested below. <br />I. A~olicantlooerator or comoanv name (name to be used on permit): ~~~CC,--x A,yCt-I l'~n~T <br />1.1 Type of organization (corporation, partnership, etc.): <br />1.2 I.R.S. Tax I.D. No. or Social Security Number: _ <br />2. Operation name (pit. mine or site Dame): <br />3. Permitted acreage (new or existing site): <br />3.l Change in acreage (+) <br />3.2 Total acreage in Permit area <br />4. Fees <br />permitted acres <br />acres <br />__~~___ acres <br />4.1 New Application 31.875.00 application fee <br />4.2 ~ New Quarry Application ~ X52.325.00 quarry application <br />4.3 Milling Application (Non-DMO) ) 33.100.00 milling application <br />Amendment Fee .,. ' -. \~ IkJt 31.550.00 amendment fee <br />_ 4.5 onversion tot 12 operation (set by statute) I'~~i.'t 31.875.00 conversion fee <br />5. Primary commoditie(s) to be mined: ~~'P~ <br />S.l Incidental commoditie(s) to be mined; 1. - Ibs/fons/vr 2. / Ibs(fons/vr <br />3. / Ibs/Tons/vr 4. / Ibslfons/vr 5. / Ibsffons/vr <br />5.2 Anticipated end use of primary commoditie(s) [o be mined: <br />5.3 Anticipated end use of incidental commoditie(s) to be mined: <br />