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TATE OF COLORADO <br />IVISION OF MINERALS AND GEOLOGY <br />apartment of Natural Resources <br />13 Sherman SL, Room 215 C O L O RA D O <br />Inver, COlOradO 80203 DIVISION O F <br />lone: (303) 86fr3567 MINERAL S <br />~X: (303) 832-8106 ~ G E O L O G Y <br />0.EClAN AT10 N•NINING <br />CONSTRUCTION MATERiAIS SAFETY•SCIENCE <br />LIMITED IlViPACT (110) OPERATION Bill Owens <br />Governor <br />RECLAMATION PERMIT APPLICATION FORM Russell George <br />Executive Director <br />Ronald W. Cottony <br />Division Director <br />IECK ONE: Then is a Fy7e Number Already A to this Operation Natural Resource Trustee <br />Pemnit # M - - (Please reference the file number clurently assigned to this operation) <br />,~_ New Application (Rule 1.4.5) Amendment Application (Rule 1.10) <br />Conversion Application (Rule 1.11) <br />Permit # ~- - (provide for Amendments aid Conversions of existing permits) <br />~ application for a Construction Materials Limited Impact (110) Operation Reclamation Permit oowtains three major parts: (1) the application <br />rm; (2) Exhibits A-J, Exhibit L, Addendum 1, auy sections of Exhibit 6.5 and Ceotechnical Stability Exhibit, as required by the Office, and <br />alined in Rules 6.1, 6.2, 6.3, 6.5, and 1.6.2(1 xb); and (3) the application fee. When you submit yoalr application, be sure to include one <br />complete signed and notarized ORIGINAL and one (1) copy of the completed application form, two (2) copies of Exhibits A-J, Exhibit L, <br />3de~ndum 1, and appropriate sectianns of 6.5 (Geotecllnical Stability Exhibit), as required, and a check fors the application fee described coder <br />below. Exhibits should NOT be bound or in a 3-ring binder; maps should be folded to 81/2" X 11" or 81/2" X 14" size. To expedite <br />~ocessing, please provide the information in the format and order described in this form. <br />GENERAL OPERATION INFORMATION <br />Type or print dearly, in the space provided, ALL information deasnbed heron. <br />Anuiicant/operator of oompanv name (name to be need on permit): ~} ry ~g,~.~ C~bt~ t;T <br />1.1 Type of organization (corporation, partnership, etc.): o c a C n v e r n m P n t <br />1.2 I.R S. Tax ID No. or Social Security Number: <br />Qperation name {pit. mine or site same): C,La r lr P ; ~ <br />Permitted acreage (new or eiiating site): <br />3.1 Chaa®e in acreage (+) <br />A _ q 5 permitted acres <br />3.2 Total Acreage in Permit Area acres <br />Fees: <br />$1,258.00 <br />4.1 New Application: -',~1~~94.{~- application fee <br />Amendment Fee (C.RS. 34-32.5-125(II)): X00- application fee <br />4.2 Conversion Fee (from I lOd to 110 x$75.00 conversion fee (Rule 1.11.2(2)) <br />~, <br />Primary commoditie(s) to be mined: San r ~a v P 1 <br />5.1 Incidental commoditie(s) to be mined: 1. C / Ib~f r~..s/yr 2. / lbs/Tons/vr 3. / lbs/T~~r <br />4. / Ibs/Tons/vr 5. / lbs/fans/yr <br />52 Anticipated end use of primary commoditie(s) to be mined: County Road Ma i n t e nor nc e <br />Anticipated end use of incidental commoditie(s) to be mined: <br />,.~-- -r r..i...~.. <br />