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DIVISION OF RECLAMATION, MINING AND SAFETY <br />Department of Natural Resources <br />1313 Sherman 5t., Room 215 <br />Denver, Colorado 80203 <br />Phone (303) 8663567 <br />FAX: (303) 832-8106 <br />CHECK ONE: <br />LIMITED IMPACT OPERATION (110(2)) <br />RECLAMATION PERMIT <br />APPLICATION FORM <br />Permit # M - (provide for conversions of existing permits) <br />STATE OF COLORADO <br />(In - aok - oa• <br />New Application (Rule 1.4) [] Conversion Application (Rule 1.11) <br />COLORADO <br />D I V I S I O N O F <br />RECLAMATION <br />MINING <br />— &— <br />SAFETY <br />The application for a Limited Impact Designated Mining Operation Reclamation Permit contains three major parts: (1) the application <br />form; (2) Exhibits A -J, any required sections of Exhibit S and Geotechnical Stability Exhibit, as required by the Office, and outlined in <br />Rules 6.1, 6.2, 6.3, 6.4.19 and 6.5; iggi (3) the application fee. When you submit your application, be sure to include one (1) gingingl <br />noginag original and one (1) copy of the application form, two (2) copies of Exhibits A -J, appropriate sections of 6.4.19 Exhibit S and 6.5 <br />(Geotechnical Stability Exhibit), as required, and a check for the application fee described under (4) below. Exhibits should not be bound <br />or in a 3 -ring binder; maps should be folded to 8 1/2" X 11" or 8 1/2" X 14" size. To expedite processing, please provide the information <br />in the format and order described in this form. <br />1. Applicant/operator or company name (name to be used on the Hermit): Shale Tech International Services <br />1.1 Type of organization (corporation, partnership, etc.): Limited Liability Company <br />2. Operation name (Hit. mine or site name): Duck Creek Mine <br />3. Permitted acreage (new or existing site): permitted acres <br />4. Fees: <br />4.1 New Application APR 0 3 2 013 S1.006.00 application fee <br />4.2 Amendment Application (from 1.10(2)) DIVISION OF RECLAMATION <br />4.3 Conversion Fee (from 110d to 110(2), (Rule 1.11.2(2))MININGAND SAFETY $1.725.00 conversion fee <br />5. )Pri®ary commodities) to be mined: Oil Shale <br />6. dame of owner to the surface of affected land: Ertl Family Partnership <br />7. Name of owner to the subsurface rights of affected land: Ertl Family Partnership <br />8. Type of mining operation: Surface 0 Underground LJ In -situ <br />Office of Office of <br />Mined Land Reclamation <br />GENERAL OPERATION INFORMATION <br />Type or print clearly, in the space provided, all information described below <br />rA <br />RECEIVED <br />5 <br />Denver • Grand junction • Durango Active and Inactive Mines <br />