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~- Sao ~ D~~ <br />_ STATE OF COLORADO <br />DIVISIONOFMINERALSANDGEOLOGY FILE COPY <br />Department of Natural Resources _ <br />1313 Sherman St., Room 215 fOR SCANN/N 1 V 1 5 I O N O F <br />Denver, Colorado 60203 <br />Phone: (303) 866-3567 <br />FAX: (303) 832-8106 <br />CONSTRUCTION MATERIALS <br />LINIITED IMPACT (110) OPERATION <br />RECLAMATION PERMIT APPLICATION FORM RE(;~e ~~ ~• <br />~UN 0 2 2004 <br />MINERALS <br />-G-E O L O G Y <br />RECLAMATION <br />MINING•SAFETY <br />Bill Owens <br />Governor <br />_ Greg E. Walther <br />CHECI: ONE: Tbere is a Fffe Number Already Assigned to this Operation Uiyision of Minerals & Gaole~cudve Director <br />Ronald W. Cattany <br />Permit # M -_-_-_ (Please ref ce the file number erurentiy assigned to this aperafion) Acting Division Director <br />New Application (Rule 1.4.5) ~ Ameadmeat Application (Role 1.10) <br />Conversion Application (Role I.I 1) <br />Perrtrit # M - (provide for Amendments and Conversions of existing permits) <br />The applicatiott for a Construction Materials Limited Impact (I10) Operation Reclamation Permit contains three major parts: (1} the <br />application form; (2}Exhibits A-J, Exhibit I, Addendum 1, any sections ofExlribit 6.5 and Geotechnical Stability Exhrbit, as required by the <br />Office, and outlined in Rules 6.1, 6,2, 6.3, 6.5, and 1.6.2(I)(b); and (3) the application fee. When yon submit your application, be sure to <br />include one (I) complete signed and notarized IVORY ORIGINAL and one (1) copy of the completed No app&cation form, irvo (2) copies <br />of Exltrbits A-1, Exhibit L, Addendum 1, and appropriate sections of 6.5 (Geoteclmical Stability Exhrbit), as required, and a check for the <br />application fee described under (4) below. Exhibits shontd NOT be boned or in a 3-ring binder, maps should be folded to 8 1/2" X 11" or <br />8 1/2" X 14" size. To expedite processing, please provide the information in the format and order described in this form. <br />CxINERAL OPERATION INFORMATION <br />1.1 Type of organization (corporation, Partnership, etc.): <br />1.2 I.RS. Tax Ip No. or Social Security Number: 2.: <br />2. Operation name foil. mine or site name): <br />3. Permitted acreaee fae~s or sestina site): <br />.~ <br />3.1 Change in acreage (+) <br />3.2 Total Acreage in Permit Area <br />4. Fees: <br />4.1 New Application: <br />Amendment Fee (C.RS. 34-32.5-125(II)): <br />4.2 Conversion Fee (from 110d to 110 875. 0 conversion fee (Rule 1.11.2(2)) <br />5. Primary cotttmoditietsl to ire mined: _~{'~ <br />_~ permitted acres <br />eereR <br />acres <br />$1.094.00 application fze <br />$719.00 application fee <br />5.1 Incidental commodiiie(s) to be mined: 1. ~(~/(g~lbs 2. / lbs/Tonslvr 3. / 1bs/Tonsivr <br />4. / lbs/Tons/vc 5. / lbs/Tons/vr <br />5.2 Anticipated end use of primary commoditie(s) to be mined: }~ ~C Na n~c t i ~ ~ t'fl ~¢c._~ <br />P.nticipated end use of incidental commoditie(s) to be mined: i~l (f121 ~ <br />or print clearly, in the space provided, ALL information described below. <br />