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DIVISION OF RECLAMATION, MINING AND SAFETY <br />Department of Natural Resources <br />1313 Sherman St., Room 215 <br />Denver, Colorado 80203 <br />Phone: (303) 866-3567 <br />FAX: (303) 832.8106 <br />LI.YIITF f) IMPACT OPERATION (110(2)) <br />O 26- RECLAMATION PERMIT <br />COLORADO <br />D 1 V 1 5 1 0 N O f <br />RECLAMATION <br />MINING <br />SAFETY <br />APPLICATION FORM RECEIVED <br />MAY ' 4 CHECK ONE: New Application (Rule 1.4) Conversion Application (Rule 1.11) Division of (reclamation, <br />Mining 8 Safety <br />Permit # M- - (provide for conversions of existing permits) <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 />Rule 6.1, b.2, b.3, 6.4.19 and 6,5; ri (3) the application fee. When you submit your application, be sure to include one (1) limed and <br />notarized original and one (1) copy of the application form, two (2) copies of Exhibits A -J, appropriate sections of 6.4. I9 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 1 I" or R lit" X 14" size. To expedite processing, please provide the information <br />in the format and order descri bed in this form. <br />GENERAL OPERATION INFORMATION <br />Type or print clearly; in the space provided, all information described below <br />l . A licant/operator or company name (name to be used on the Permit): <br />1.1 Type of organization (corporation, partnership, etc.): <br />2. Operation name it mine or site name) <br />3, Permitted_ a_ creage fnew or existing site): <br />permitted acres <br />4. Fees: <br />4.1 New Application $1_ , 0 06.00 application fee <br />4.2 Amendment Application (from 1.10(2)) <br />4.3 Conversion Fee (from I IOd to 110(2), (Rule 1. 11.2(2)) <br />$1.725.00 conversion fee <br />5. Primary comm ad.. (s) to be mined: <br />6. Name of owner to the surface of affected land• <br />7. Name of owner to the subsurface rights of affected land • `"\�b ` X t > t 14--1 <br />8•e of raring operation n n <br />Surface ET Underground Lam. In -situ <br />Office of <br />Mined land Reclamation Denver o Grand junction . Durango Office of <br />Active and Inactive Mines <br />