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STATE OF COLORADO <br />- DIVISION OF RECLAMATION, MINING AND SAFETY RECEIVED <br />Department of Natural Resources <br />1313 Sherman SL, Room 215 <br />Denver, Colorado 00203 APR 0 6 2017 D o L o R w n o <br />DI l V IS 1 ON O F <br />Phone: (303) 8663567 RECLAMATION <br />FAX: (303) 832-8106 DIVISION OF RECLAMATION MINING <br />MINING AND SAFETY SAFETY <br />LIMITED IMPACT OPERATION (110(2)) <br />RECLAMATION PERMIT <br />APPLICATION FORM <br />2017--017- <br />CHECK ONE- IZI New Application (Rule 1.4) Conversion Application (Rule 1.11) <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 />Rules 6.1, 6.2, 6.3, 6.4.19 and 6.5; end (3) the application fee. When you submit your application, be sure to include one (1) signed and <br />notarized original and one (1) copy of the application form, two (2) copies of Exhibits A4, 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 8 112" X 14" size. To expedite processing, please provide the information <br />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 />1. Applicantloperator or company name (name to be -used on the permit). AMAZON ITE MINING, LLC <br />1.1 Type of organization (corporation, partnership, etc.): LIMITED LIABILITY COMPANY <br />2. Operation name (pit, mine or site name): FORREST MINING PROJECT <br />3. Permitted acreage (new or existing site): 9.9 permitted acres <br />4. Fees: <br />4.1 New Application $1.006.00 application fee <br />4.2 Amendment Application (from 1.10(2)) <br />4.3 Conversion Fee (from 1 l Od to 110(2), (Rule 1. 11,2(2)) $1.725.00 conversion fee <br />5. Primary cotrumoditle(s) to be mined- GEMSTONES <br />6. Name of owner to the surface of affected land: U.S.D.A. FOREST SERVICE <br />7. Name of owner to the subsurface rights of affected land: JEFFREY S. FORREST $ BETSY C. FORREST <br />8. kin of mirting o eration: Z Surface Underground E] In-situ <br />Office of Office of <br />Mined Land Reclamation Denver - Grand Junction - Durango Active and Inactive Mines <br />