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A, <br /> 3 = ! COLORADO <br /> Division of Reclamation,Ala v , <br /> Mining and Safety . JL7 <br /> D,partinew of Natural Resources <br /> 1313 Sherman Street, Room 215 <br /> Denver, CO 80203 <br /> RECEIVED <br /> LIMITED IMPACT OPERATION(110(1)) <br /> RECLAMATION PERMIT AUG 01 2014 <br /> APPLICATION FORM Division of Reclamation, <br /> Miming&Safety <br /> CHECK ONE: X New Application Conversion Application(Rule 1.11) <br /> Permit#M- - (provide for conversions of existing permits) <br /> The application for a Limited Impact 110(1) Mining Operation Reclamation Permit contains three major parts: (1)the application form; <br /> (2)Exhibits A-J, any required sections of Exhibit S and Geotechnical Stability Exhibit, as required by the Office, and outlined in Rules <br /> 6.1, 6.2, 6.3, and 6.5; and (3) the application fee. When you submit your application, be sure to include one(1) signed and notarized <br /> original and one(1)copy of the application form,two(2)copies of Exhibits A-J,and 6.5(Geotechnical Stability Exhibit),as required,and <br /> a check for the application fee described under(4)below.Exhibits should not be bound or in a 3-ring binder;maps should be folded to 8 <br /> 1/2"X l l"or 8 1/2"X 14"size. To expedite processing,please provide the information in the format and order described in this form. <br /> GENERAL OPERATION INFORMATION <br /> Type or print clearly,in the space provided,all information described below <br /> 2 <br /> NCB^ <br /> 1. A licant/o erator or com an name name to be used on the er it : <br /> 1.1 Type of organization(corporation,partnership,etc.): ►� l �i lti� <br /> 2. Operation name(pit,mine or site name): I^ �- <br /> 3. Permitted acreage(must be 5 acres or less): _permitted acres <br /> 4. Fees: <br /> 4.1 New Application $288.00 application fee <br /> 4.2 Amendment Application $661.00 amendment fee <br /> 4.3 Conversion Fee(from 110(2)to I10(1),(Rule 1.11.2(2)) 1 1 $288.00 conversion fee <br /> 5. Primary commoditie(s)to be mined: 0 7 f ol— /e_ T <br /> 6. Name of owner to the surface of affected land: ki ► 0Q 0, <br /> 7. Name of owner to the subsurface rights of affected land: �,' & <br /> 8. Type of mining operation: Surface Fl Underground Dlacer M g 7 <br /> %n Cam' <br /> 1313 Sherman Street,Room 215, Denver, CO 80203 P 303.866.3567 F 303.832.8106 http://mining.state.co.us I <br /> John W. HickenlooDer, Governor I Mike Kine, Executive Director I Vireinia Brannon, Director * . ,* <br />