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<br />LIMITED IMPACT OPERATION (110) <br />APPLICATION FORM <br />Owners(s) of Substance to be Mined <br />(check applicable box(s)): <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 check 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 />GENERAL OPERATION INFORMATION <br />Type or print clearly, in the space provided, all information described below. <br />----=------------------------------------------------------------------------------------ <br />----------------------------------------------------------------------------------------- <br />1. Applicant/Operator Name: (%,v -.To~/NSTO,f/ <br />2. Operation Name (Pit, mine or site name): G'/C,v ToN.ysToN ~T~ / /~'l- ~-z-oy~ <br />3. Application type: Limited Impact Operation (110). <br />4. Application Fee for Permitted Acreage* <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. <br />5. Substance(s) to be mined (e. g., gold/silver/gravel) <br />6. <br />7. <br />8. <br />9. <br />Owner(s) of Record of Affected Land <br />(check applicable box(s)): <br />Type of Mining Operation <br />(check applicable box(s)) <br /> <br />~e~ •~J z/,~/&7 <br />~' permitted acres. <br />~ 7S ~~ application fee. <br />C~AuE ~ <br />~~ivate ^ State ^ Federal ^ Indian <br />[s3~Private ^ State ^ Federal ^ Indian <br />F~Surface ^ Underground ^ In-situ <br />Location Information. The center of the area where the majority of mining will <br />occur lies in: <br />COUNTY: ~ //G-2 <br />PRINCIPLE MERIDIAN chec one ~ ~th (Colorado) ^ 10th (New Mexico)^ Ute <br />TOWNSHIP (write number arid check direction): T ^ North C~South <br />RANGE (write number and check direction): R ~ ^ East Q~West <br />SECTION (write number): S 3 3 <br />QUARTER SECTION (check one): ^~1~ ^ NW CASE ^ SW <br />QUARTER/QUARTER SECTION (check one): ^ NE ^ NW p~SE ^ SW <br />GENERAL DESCRIPTION: <br />(miles and direction 3M//ES ~,45T tl ~~uii~E ~o/a• <br />from nearest town and <br />approximate elevation) $ 7S O <br />* If the operator is a unit of State or county government, an application fee is not <br />required. A fraction of an acre must be counted as one acre for fee calculation. <br />