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° ~9 - ~oa7~ 03~ <br />STATE OF COLORADO <br />DMSION OF R&CIAMATiON, MINING AND SAfEiY <br />7M Natural Resources <br />7313 Shemwn SL, RDOm 275 <br />C O L O R A D O <br />Denver Colorado 80203 DIVISION OF <br />Phone: (303) 86(x3567 RECLAMATION <br />fA)E (303) 8328706 MINING <br /> - &- <br /> SAFETY <br /> CONSTRUCTION MATERIALS <br /> LIMITED IMPACT (110) OPERATION a'll o"'°" <br /> ememor <br /> RECLAMATION PERMIT APPLICATION FORM wuseli George <br /> Executive Director <br /> Rwtaald W. Uttany <br />CHECK ONE: There is a File Number Already Atangned to the Operation o""SO" o1feCtOf <br /> Natural Resowee Trustee <br />Permit # M -_ - - (Please reference the file number curten0y assigned W this operation) <br />X New Application (Role 1.4.5) Aurendmertt Application (Rule 1.10) <br /> Conversion Application (Rule 1.11) <br />Permit # M - -- (provide for Avrendments and Coaversiois of existing permits) <br />The applit~tion for a Construction Materials Limited Impact (110) Operation Reclaimtitm Pemtit contair7s three major parts: (1) the <br />application form; (2) Fad7/biCS A-J, Exhibit I„ Addendumn 1, a~ sections oflsxhrbit 6.5 and Geotechnical Stability F.xh7bi; as required <br />by the Office, and outlined m Rules 6.1, 6.2, 63, 6.5, and l.ti.2(1Mb), and (3) the application fee. When you sub~tyour appliwtioq be <br />sure to include one (1) coamlae siffied and notarized ORIGWAL and ilk (1) copy ofdre completed application fomt, two (2) copies <br />of Exhibits A,1, Exhibit L, Addendum I, and appropriate stxtiortsof 6.5 (Geotechnical Stability Exhibit), as required, at7d a check for <br />the application fee dtsatbed under(4) below. Exhibits should NOT be bound or in a 3-ring binder, amps should be folded ro 8 112" X <br />11" or 8 l/2" X 14" size. To expedite processing, please provide the infornmtion in the fomlat snd order tlescnbed in this form. <br />GENERAL OP1alATtON QdFORMATJON <br />Type or print dearly, hn Its space provided, ALL informtion deserihed blow. <br />1. Attilicant/ocerator or eompanrname fname ro be used on iermhtl: S ~ S Service s <br />1.1 Typeoforgan®tion(cotporadon,parmnship,NC.): Sole Proprietorship <br />Z. Ooeration name foil Wise ar site /tarlitl: Lopez Quarry No , 2 <br />3. 1!ermilted sereaae (new or ezisNrm site): 9.8 permitted acres <br />3.1 Change in acreage (+) acres <br />3.2 Total Acreage in Permit Area acres <br />4. Fees: <br />4.l New Applicatiore $1.094.00 application fee <br />Arne~~nt Fee (C.1LS. 34-32.5-125(II)): 5719.00 application fee <br />4.2 Conversion Fee (from 110d w 110 8a 7s•00 conversion fee (Rule 1.11.2(2)) <br />5. Primarvconmgdifie(sltobet®tsd: Sand & Gravel Soil <br />5.1 Incidental co®nodiGe{s) to be mined: 1. l IlalTo~lvr 2. / Ibsl1'ons/vr 3. / ibarl'ons/vr <br />4. ! Rts/fons/vr 5. 1 ibsffons/vr <br />5.2 Amicipated end use of primary cormrioditie(s) to be mined: <br />Anticipated end use of incidental coimioditie(s) to be mined: <br />Road Construction <br />Surfacing and Fili <br />Once of <br />Mined Land Reclamation <br />Office of <br />Active ark Inac7ive Mutes <br />