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II'II'II'I"f"1~' <br />LIMITED IMPACT' OPERATION (110) <br />RfiCLAMATION PERMIT <br />APPLICATION FORM <br />Una ) 1 1Qy4 ~~1' x=11 <br />~,1iuiU0~ Os w,ne~a~s S ue°~04~' <br />CHECK ONE: ,~ New App l))i,, c/IaCion (Rule 1.4) Conversion Application (Rule 1.11J <br />Permit # M CI`i -~ (provide for conversions of existing permits) <br />The application for a Limited Impact Designated Mining Operation Reclamation PermiC contains <br />chree major parts: (1) the application form; (2) Hxhibits A-J, any required sections of <br />Exhibit S and Geotechnical Stability Hxhibit, as required by the Office, and outlined in <br />Rules 6.1, 6.2, 6.3, 6.4.19 and 6.5; an (3) the application fee. When you submit your <br />application, be sure to include one (1) sicmed and notarized original and one (1) copy of the <br />application form, two (2) copies of Hxhibits A-J, appropriate sections of 6.4.19 Exhibit S <br />and 6.5 (Geotechnical Stability fixhibit), as required, and a check for the application fee <br />described under (a) below. Hxhibits should not be bound or in a 3-ring binder; maps should <br />be folded to 8 1/2" X 11" or 8 1/2" X la^ size. To expedite processing, please provide the <br />information in the format and order described in this form. <br />GHNfiRAL OPERATION INFORMATION <br />Type or print clearly, is the space provided, all information described below. <br />a 6 3v c 9~ 3 v n .O 3 <br />1. Applicant/operator name: <br />1.1 Type of organization <br />1.2 I.R.S. Tax ID No.: <br />2. Operation name (pit, mine or site name) : ~ Nss r/l T~ ra / c ~ % , >< <br />3. Permitted acreage (new or existing site): fi0 permitted acres <br />3.1 Change in acreage (+ or -) n/(A acres <br />4. Fees: <br />4.1 New Application 5875.00 application fee <br />4.2 Conversion Fee (from 110d to 110 875 00 conversion fee (Rule 1.11.2(2)) <br />5. Primary commoditie(s) to be mined: ~r r <br />6 . Name of owner to the surface . of affected land: ~ n „ / r_ J ~4 S C Y ~/ <br />~ -7' <br />7. Name of owner to the subsurface rights of affected land: ~~ o~i~e ./ ~rs~~~ <br />8. Type of mining operation: ~ Surface _ Onderground _ In-situ <br />9. Location information. The enter of the area wee the majority of mining will <br />occur lies ia: j ,,. -~~~ <br />COIIN'SY : Y.t]N <br />PRINCIPAL MHRIDLAN (check one): _ 6th (Colorado) 10th (New Mexico) _ IIte <br />SECTION (write number): S <br />TOWNSHIP (write number and check direction): T ~ yNOrth South <br />RANGH (write number and check direction): R ,~ _ Hast /Weet <br />QUARTfiR SECTION (check one); _ NH 1C NW K Sfi _ SW ,' <br />QQARTfiR/QIIARTHR SECTION (check one): _ NH _ NW ~ SH _ SW <br />GfiNERAL DHSCRIPTION: (miles and direction from nearest town and approximate <br />elevation) _ `~. '~2 „n ;1 rs i., .,~ r-ri ~ F l.)rL/.'_~<lo~. C.!) /?a<f off' 2-~5- <br />10. Correspondence Information: <br />APPLICANTIOPERATOR (name, address, and phone of name to be used on permit) <br />individual's Name: v ~ s i Title: r~.,~ ~ e.- <br />Social Security No.: .`i ~ 3 ~ ~/ ~ - `.>_ / <br />Company Name: <br />street: / 2 02 ~/ Y d/- Lv ~_„ l d. .~-'-.~' <br />C U U N F <br />