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• ~RECE4VE® <br />~uN i o tsar <br />LIMITED IMPACT OPERATION (110) _ MINED LAND <br />APPLICATION FORM ~fECLAMATION DIVISION <br />This form contains two major parts: {1) General Operation Information and (2) Exhibits <br />A-G. When you submit your application, be sure to include two signed copies of the <br />General Operation Information, two copies of Exhibits A-G, and a c e k for the <br />application fee described under (4) below. To expedite processing, please provide the <br />information in the format and order described in this form. <br />________'_____________________________________________________m _~ ~__~~ ~____________ <br />GENERAL OPERATION INFORMATION <br />Type or print clearly, in the space provided, all information described below. <br />1. Applicantl0perator Name: lE. Sims ('a ayel Co, <br />2. Operation Name (Pit, mine or site name): East Douglas Pit <br />3. Application type: Limited Impact Operation (1101. <br />4. Application Fee for Permitted Acreage* 3 permitted acres. <br />(E10 x (affected acres) + E25.00).* <br />Note permitted acreage and application fee and <br />attach a check for this amount when you file. ;55.00 application fee. <br />5. Substance(s) to be mined (e. g., gold/silver/gravel): Grivel <br />6. Owners(s) of Substance to be Mined <br />(:heck applicable box(s)): ^ Private ^ State IJ Federal ^ Indian <br />7. Owner(s) of Record of Affected Land <br />(check applicable box(s)): ^ Private ^ State p Federal ^ Indian <br />8. Type of Mining Operation <br />(check applicable box(s)): Q Surface ^ Underground ^ In-situ <br />9. Location Information. The Center of the area where the majority of mining will <br />occur lies in: <br />COUNTY: (IFlv~Lo <br />PRINCIPLE ME IDIAN check one D 6th (Colo rado) ^ 10th (New "texico)^ Ute <br />TOWNSHIP (write number and check direction): T Z ^ tJorth ^ South <br />RANGE (write number and check direction): R ~L ^ East © West <br />SECTION (write number): S ?5 <br />QUARTER SECTION (check one): per- ^ NW p SE ^ SW <br />QUARTER/QUARTER SECTION (check one): p NE ^ NlJ ^ SE ^ SW <br />GENERAL DESCRIPTION: <br />(miles and direction AyL~rcximateiy ?i ~;i.,r; nnnih nP Rangely ri. :Oy0 <br />from nearest town and <br />approximate elevation) <br />* If the operator is a unit of State or county governme nt, an application fee is not <br />required. A fraction of an acre must be counted as one acre for fee calculation. <br />