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LIMITED IMPACT OPERATION (110(2)) RECLAMATION PERMIT APPLICATION FORM The application for a Limited Impact Operation Reclamation Permit contains three major pafis: (1) the application form; (2) Exhibits A-J; and, (3> the application fee. When ~ you submit your application; be sure to fnclude two <2> signed originals of the application form, two (2) copies of Exhibits A-J, and a check for the application fee described under (3) below. To expedite processing, please provide the information 1n the format and order described in this form. _ - av=eve===ec==ovc=v====c==ax=a==a==aa=aaa=avsacaaaavaaaaaasaavv a:aaaaavaaaa=aaav==-_--____ GENERAL OPERATION INFORMATION Type or print clearly, in the space provided, all information described below. aavvaaaaaaa=aaaaa=aaa==va=va===v======e=x=v===c======a===v==va=aa=aa=aaaavaaavavaavaaavav 1. Applicantloperator name: Jim vanella 1.1 Type of organization (corporation, partnership, etc.): lndividualls 2, Operation name (pit, mine or site name): rr~Tn uncnr 2.1 I.R.S. Tax ID No. or Social Security No.: 3. Permitted acreage 3 permitted acres 3.1 Application Fee 8875.00 application fee 4. Substance(s) to tie mined (e.g., gravel/gold/borrow): GOLD 5. Name of owner of surface of affected land: Tim vanella 6. Name of owner of subsurface rights of affected land: Jim vanella 7. Type of mining operation: ` Surface _ Underground _ In-situ 8. Location information. The center of the area where the majority of mining will occur lies in: COUNTY: ^ii^.r't~ i;i; PRINCIPAL MERIDIAN (check one): x 6th (Colorado) 10th (New Mexico) Ute TOWNSHIP (write number and check direction) : T 12 North yx, _ South RANGE (write number and check direction): R F30 _ East xy„ West SECTION (write number): S 5 QUARTER SECTION (check one): )()c NE NW SE _ SW QUARTER/QUARTER SECTION (check one): _ NE _ _ NW ~ SE _ SW GENERAL DESCRIPTION: (miles and direction ~ 1~9 r•T--.~ ~'~uST ~F GRAIdITF. CR. .'E298 from nearest town and approximate elevation) 12,000 Ft.