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• iiiiiiiii-iumiii <br />DIVISION OF MINERALS AND GEOLOGN <br />UepanmeN of Natural Resuurcrs <br />1373 Sherman SL, Room 215 <br />Denver. Colorado 80203 <br />Phone: 13011866-3567 <br />fAX: U03) 83]-81(16 <br />CONSTRUCTION MATERIALS <br />~ ,o~~ <br />3o9s <br />OF ~OLORP~~O <br />RECEIVED DIVISION OF <br />MINERALS <br />JUL2p20~ GEOLOGY <br />RECLAMATION' <br />Division of Minerals i GtObgy i 111 N I N G• S A F E T Y <br />LIMITED IMPACT (110) OPERATION <br />Bill Owens <br />Governor <br />Greg E. W alcher <br />RECLAMATION PERMIT APPLICATION FORM Erecmwe Durctur <br />Michael B. long <br />Division Director <br />CHECK ONE: ~ New Application (Rafe 1.4) Conversion Application (Rule 1.11) <br />Amendment Application (C.R.S. 34-32.5-110) <br />Permit # M ~QQ-~-_ (provide for Amendments and Conversions of existing permits) <br />The application for a Construction Materials Limited Impact (I 10) Operation Reclamation Permit contains three major parts: (1) the application form; <br />(2) Exhibits A-1, Exhibit L, Addendum 1, any sections afExhibit 6.5 and Geotechnical Stability Exhibit, as required by the Office, and outlined in Rules <br />6.1, 6.2, 6.3, 6.5, and 1.6.2(1)(6); and (3) the applicazion fee. When you submit your application, be sure to include one (1) complete si¢ned and <br />notarized IVORY ORIGQt1AL and one (1) copy of the completed Ivor application form, two (2) copies of Exhibits A-], Exhibit L, Addendum 1, and <br />+ppropriate sections of 6.5 (Geotechnical Stability Exhibit), as required, and a check for the application fee described under (4) below. Exhibits should <br />NOT be bound or in a 3-ring binder, maps should be folded w 8 12" X 11" or 8 12" X 14" size. To expedite processing, please provide the information <br />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 />I. Apolicaot/ooeretor or eomnanv Dame (name to be used on cermitl: Lou`tonlt!Al ~KOS. 5 TOA)E <br />1.1 Type oforgan'vation (corporation, partnership, etc.): S CoRPORArio~1 <br />1.2 I.R.S. Tax 1D No. or Social Security Number: <br />2. Oceretion Dame (nit- mine or site namel: Ly KIAJS <br />3. Permitted atreaee (new or ezistine sitel: ~~_ permitted acres <br />3.1 Change in acreage (+) acres <br />Total Acreage in Permit Area g . q acres <br />4. Fees: <br />4.1 New Application: 675.00 application fee <br />Amendment Fee (C.R.S. 34-32 S-i25(il)): 575.00 application fee <br />4.2 Conversion Fee (from I I Od to 1 10 875.00 conversion fee (Rule 1.11.2(2)) <br />5. Primary commoditie(s) to be mined: SAa051vA1E ()plJ\n11TC <br />5.1 Incidental commoditie(s) to be mined: 1. won/ ~orX Ibsllons/vr 2. 500 / ror~ Ibs/Tons/vr 3. / Ibsrl'ons/vr <br />4. / Ibs/i'ons/vr 5. / Ibs/fons/vr <br />52 Anticipated end use of primary commoditie(s) to be mined: ~LLSIOI A16 + L,~ r1D SGA VF <br />5.3 Anticipated end use of incidental commoditie(s) to be mined: ~AD F,oF,E <br />