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STATE OF COLORADO <br />DIVISION OF RECLAMATION, MINING AND SAFETY <br />Department of Natural Resources <br />1313 Sherman St., Room 215 <br />Denver, Colorado 80243 <br />Phone: (303) 866 - -3567 <br />FAX: (30W E I Y E D <br />LMI[TED IMPACT OPERATION (110(2)) <br />�f <br />14 2313 RECLAMATION PERMIT <br />DIVISION OF RECLAMATION APPLICATION FORM <br />MINING AND SAFETY <br />CHECK ONE: IZI New Application (Rule 1.4) Conversion Application (Rule 1.11) <br />Permit it M -2013 _ 041 (provide for conversions of existing permits) <br />COLORADO <br />D I V I S I O N OF <br />RECLAMATION <br />MINING <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; and (3) the application fee. When you submit your application, be sure to include one (1) signed an <br />notarized 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 8 112" 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 />2. <br />GENERAL OPERATION INFORMATION <br />Type or print clearly, in the space provided, all information described below <br />Awfleantloperator or company name (name to be used on the permit): Brian Busse <br />1.1 Type of organization (corporation, partnership, etc.): <br />Operation name (pit, mine or site name): Thank You Lord Claim <br />3. Permitted acreage (new or existing site): <br />4. Fees: <br />4.1 New Application <br />4.2 Amendment Application (from 1.10(2)) <br />4.3 Conversion Fee (from 110d to 110(2), (Rule 1. 11-2(2)) <br />5. Primary commoditie(s) to be mined: Gemstones <br />6. Name of owner to the surface of affected land: U.S. forest Service <br />7. Name of owner to the subsurface rights of affected land: Brian Busse <br />8. Type of mining operation: W1 Surface Underground F] In -situ <br />9 permitted acres <br />$1006.00 application fee <br />$1.725.00 conversion fee <br />Office of Office of <br />Mined Land Reclamation Denver • Grand Junction • Durango Active and Inactive Mines <br />