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~ for ass td AY 00 199' MINED LAND LIMITED IMPACT OPERATION (110(2) ) RECLAMATION DIVl~' -~: 7 APPLICATION FORM The Application for a Limited Impact Operation Reclamation Permit contains Uiree major parts: (1) the Application Form, (2) the Application Exhibits A-F, and (3) the application fee. When you submit your Application, be sure to include two signe~d~copies of the Application Form, two copies of Exhibits A-F, and a check for the appTic~a ion fee described under (4) below. To expedite processing, please provide the information in the format and order described in this form. ~_q~_-~~ ------------------------------------------------------------------ ---------------------- GENERAL OPERATION INFORMATION Type or print clearly, in the space provided, all information described below. 1. Applicant/Operator Name: 2. Operation Name (Pit, mine or site name): ~/f~/S. /~.4G-ESnN G-3 f~E~E (~/T 3. Application type: Limited Impact Operation (110). 4. Application fee for Permitted Acreage* (S10 x (affected acres) + ;25.00).* Note permitted acreage and application fee and attach a check for this amount when you file. 5. Substance(s) to be mined (e.g., gold/silver/gravel) 6. Owners(s) of Substance to be Mined (check applicable box(s)): ~ Private 7. Owner(s) of Record of Affected Land ,permitted acres. b /U~ application fee. ~A~U~L _ State _ Federal ` Indian (check applicable box(s)): (Private ` State _ Federal _ Indian 8. Type of Mining Operation (check applicable box(s)): ~ Surface _ Underground i In-situ 9. Location Information. The center of the area where the majority of mining will occur lies in: COUNTY: ~~/!+S l /)l Cr TD /lI PRINCIPLE A ec one 6th (Colorado) 10th (New Mexico) Ute TOWNSHIP (write number and check directio n): T J'' ~ North South RANGE (write number and check direction): R East ~ West SECTION (write number): S _ QUARTER SECTION (check one): NW ~( SE SW QUARTER/QUARTER SECTION (check one): ; NE ~ NW i SE _ SW GENERAL DESCRIPTION: (miles and direction f-S M,~.~S NU RTrf ANA 9M~~. is ,~1nST' of d l /S from nearest town and U° ado approximate elevation) ~3oO * If the operator is a unit of State or county government, an application fee is not required. A fraction of an acre must be counted as one acre for fee calculation.