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i III IIIIIIIIIIIIIIII~ 999 LIMITED IMPACT OPERATION (110(2)) ,~ , -,, APPLICATION FORM ~ ~ ~' ~~~~„~ The Application fora Limited Impact Operation Reclamation Permit contains thresfti~m~or parts: (1) the Application Form, (2) the Application Exhibits A-F, and (3) the i,~.,J, application fee. When you submit your Application, be sure to include two signed copies of the Application Form, tvro copies of Exhibits A-F, and a check for the app rca ion fee described under (4) below. To expedite processing, please provide the information in the format and order described in this form. ______________________________________________ ~1_QS?-=1~~ ==._1_ya~7_====________ GENERAL OPERATION INFORMATION Type or print clearly, in the space provided, all information described below. 1. Applicant/Operator Name: Herown En 2. Operation Name (Pit, mine or site name): ises MARTIN PIT 1-A 3. Application type: Limited Impact Operation (110). 4. Application Fee for Permitted Acreage* 9.32 permitted acres. ($10 x (affected acres) + E25.00).* Note permitted acreage and application fee and attach a check for this amount when you file. $125.00 application fee. 5. Substance(s) to be mined (e.g., gold/silver/gravel): SAND & GRAVEL 6. Owners (s) of Substance to be Mined (check applicable box (s )): XX Private _ State _ Federal _ Indian 7. Owner(s) of Record of Affected Land (check applicable box (s )): X~ Private _ State _ Federal _ Indian 8. Type of Mining Operation (check applicable box (s )): XX_ Surface _ Underground _ In-situ 9. Location Information. The center of the area where the majority of mining will occur lies in: COUNTY: MOFFAT PRINCIPLE MERIDIA c ec one 6th olorado) 10th (New Mexico) Ute TOWNSHIP (write number and check di n.): T 6 XX North South RANGE (write number and check direction): R 91 _ East ~j West SECTION (write number): S QUARTER SECTION (check one): ~ ~ NW SE SW QUARTER/QUARTER SECTION (check one): _ NE _ NW ~ SE _ SW GENERAL DESCRIPTION: (miles and direction 2i MILES $OUTfi OF ~RAIG~ COLD from nearest town and approximate elevation) 64R(1 AnnvF SFA 1-FVF~ ~ ~~ * If the operator is a unit of State or county government, an application fee is not required. A fraction of an acre must be counted as one acre for fee calculation.