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TATE OF COLORADO <br />DIVISION OF MINERALS AND GEOLOGY f <br />Department of Natural Resources <br />1313 Sherman St., Room 215 <br />Denver, Colorado 80203 <br />Phone: (3031866-3567 CONSTRUCTION MATERIALS RECE~ VE® <br />FAX: (303) 832106 lr <br />LIMITED IMPACT (110) OPERATION <br />F I LIE9L C0f PY R/E~CLAMATION PERMIT APPLICATION FORM APR 2 t~ ZQ(J~j~/ <br />®K (a/. a A~A~,~/' Uirislon of Minerals and Ceology <br />CHECK ONE: There is a File Numpberlilready Assigned to this Operation <br />Permit # M - ttD~- ~ 2 p (P/lease reference the file number currently assigned to this operation) <br />New Application (Rule 1.4.5) Amendment Application (Rule 1.10) <br />Converoion Application (little 1.11) <br />Permit # M -_ -_ (provide for Amendments and Conversions of existing permits) <br />COLORADO <br />DIVISION O F <br />MINERALS <br />GEOLOGY <br />0.ECLANAtION•N WING <br />SAFETY•SCIENCE <br />Bill Owens <br />Governor <br />Greg E. Walther <br />Executive Director <br />Ronald W. Caaany <br />Division Direttor <br />Natural Resource Trustee <br />The application for a Construction Materials Limited Impact (110) Operation Reclamation Perndt txmtains three majorpalts: (t) the application <br />form; (2) Exhibits A-J, Exhibit L, Addendum t, any sections of Exhibit 6.5 and Geotechnical Stability Exhibit, as required by the Office, and <br />outlined in Rules 6.1, 6.2, 6.3, 6.5, and 1.6.2(1)(6); and (3) the application fee. When you submit your application, he sure to include one <br />(1) complete sued and notarized IVORY ORIGINAL and one (I) wpy of the completed Ivory application form, two (2) copies of Exhibits <br />A-J, Exhibit L, Addendtan 1, and appropriate sections of 6.5 (Geotechnical Stability Exhibit), as required, and a check for the application fee <br />described under (4) below. Exhibits should Nom( T be bound or in a 3-ring binder; maps should be folded to 8 I /2" X 11" or 8 I /2" X l4" size. <br />To expedite processing, please provide Ute information in the format and order described in this form. <br />GENERAL OPERATION INFORMATION <br />Type or print ckady, in the apace provided, ALL informatioe described below. <br />1. A~rplicaHUoaerator or rnrgpanv name (name to be used on Hermit): ~E$R12AR`0 SR4~IOA/ `~ . `~ <br />1.1 Type of organization (corporation, partnership, etc.): S OC.E PROF'R /F % 0 2 <br />1.2 1.2 I.R.S. Tax ID No. or Social Security Number: Tq~ I ~ . 8~ ~' 063 7 ~ 9f° <br />2. Operation name (Hit, mine or ake Hamel: TNF 8~p~~.SS ~/ <br />3. Permitted acreat=_e (Hew or eiistin¢ aitel: 9• q ~ permitted acres <br />3. ] Change in acreage (+) acres <br />32 Total Acreage in Permit Area acres <br />4. Fees: <br />4. ] Nea~ Application: $1.094.00 application fee <br />Amendment Fee (C.R.S. 34-32.5-125(II)): $719.00 application fee <br />4.2 Conversion Fee (from I 1 Od to 110 875.00 conversion fee (Rule 1.11.2(2)) <br />6. Primary rnmmodkiefs) to be mined:~~, <br />5.1 Incidental commoditie(s) to be mined: 1. / ]bs/Tonsh~ 2. / Ibs/Tons/yr 3. / lbs/I'onshT <br />4. / Ibs/Tons/vr ~. / IbslTonshT <br />5.2 Anticipated end use of primary commoditie(s) to be mined: L~'DA~ I3A~ <br />Anticipated end use of incidental commoditie(s) to be mined: <br />Office of Office of Colorado <br />Mined Land Reclamation Active and Inactive Mines Geological Survey <br />