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~~ APPLICANT'S QUE~ONNAIRE ~0 THE COLORADO DIYISI~ 3WILOLIFE ~XF~iE3~ T <br />For Limited Impact Operations <br />(Permit 110-1 and 110-2) or . ~ - Z <br />Regular Operations Permit 112) , <br />Instructions to the a licant: Complete both sides of this form. Send the <br />comp e e orm o e appropr a e Division of Wildlife (DOW) Regional Manager. <br />Re tonal Mana ers: <br />Reg on: 7 Independent Avenue Grand Junction, CO 81505 <br />NE Region: 317 w. Prospect Averwe Ft. Collins, CO 80526 <br />Central: 6060 Broadway Denver, CO 80216 <br />SW Region: 2300 S. Townsend Avenue Montrose, CO 81401 <br />SE Region: 2126 N. Weber Colorado Springs, CO 80907 <br />To expedite processing, please provide the information in the Format and order <br />described in this form. Type or print clearly. Incomplete questionnaires will be <br />returned. Please allow 30 days for processing of completed form. Your cooperation <br />is appreciated. <br />PLEASE ATTACH THE FOLLOWING INFORMATION TO THIS FDRM: <br />A. Minin and Reclamation Plan: Description of proposed reclamation plan or <br />su t g atW Rec amat on Plan as prepared for MLRD application. <br />B. Mates: Submit copies of maps for the both the Mining Plan and the Reclamation <br />an, Suggested maps are those prepared for the MLRD application. <br />For the 110-1 Permit, Two Acre Limited Impact Operation: Exhibit A - Location <br />Map Exhibit C - Affected Lands Map. <br />For the 110-2 Permit, Limited Impact Operation: Exhibit E - Mining Plan Map <br />and Reclamation Plan Map. <br />For the 112 Permit, Regular Operation: Exhibit C - Pre-Mining and Mining Plan <br />Map(s) of Affected Lands, and Exhibit F -Reclamation Plan Map. <br />----------------------- <br />1: Operation Hama (pit, mine):'~u'7TL~ PST iJo. I <br />2. Application type (check one): Two Acre limited Impact Operation (110-1) <br />~-LLnited Impact Operation (110-2) <br />- Regular Permit Operation (112) <br />3. Name of applicant/operator: M°FF~,.T ,~„~„~-I 'T2oaD l~~o ~,,n _ rr <br />Address • P 0 . ~o tC Le L -7 <br />Phone Number :~30~~ Qi 2 5t -'32 I 1 <br />4. Name of contact person (iP different from above): Mw2~/~~.I M a orz fem. <br />Address: SAM~L <br />Phone NurtibeT: Sr4M ~ ' <br />5, Location of mine: Md~,4f[~,,~,~ ~ -'r~j~(, Q,q~ <br />~'1 (County, Town-Fsi'i_p, Range, Section to near st quar <br />'~,,J' (OVER) <br />- -10- <br /> <br />