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COLORADO <br />Av- <br />Division of Reclamation, <br />Mining and Safety <br />Department of Natural Resources <br />1313 Sherman Street, Room 215 <br />Denver, CO 80203 <br />CHECK ONE: -aNew Application <br />Permit # M- - <br />MU 1s-012 <br />-mac, whe <br />4� uwaov <br />LIMITED IMPACT OPERATION (110(1)) <br />RECLAMATION PERMIT <br />APPLICATION FORM <br />Ja Conversion Application (Rule 1.11) <br />(provide for conversions of existing permits) <br />RECEIVED <br />MAR 2 3 2018 <br />DIVISION OF RECLAMATION <br />MINING AND SAFETY <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 11" 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 />1. Applicant/operator or company name (name to be used on the permit): �{ <br />2. <br />1.1 Type of organization (corporation, partnership, etc.): _ <br />Operation name (pit, mine or site name): +* t"-bC1'r3 <br />3. Permitted acreage (must be 5 acres or less): <br />4. Fees: <br />'0 permitted acres <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 110(1), (Rule 1. 11-2(2)) $288.00 conversion fee <br />5. Primary commoditie(s) to be mined: abtj 4- 71(ate <br />6. Name of owner to the surface of affected land: U5 Fvres � 4;[f V (J-` <br />7. Name of owner to the subsurface rights of affected land: 3J 6 dv <br />8. Type of mining operation: _a Surface ffL Underground IIPlacer <br />.Co <br />1313 Sherman Street, Room 215, Denver, CO 80203 P 303.866.3567 F 303.832.8106 http://mining.state.co.us �c <br />John W. Hickenlooper, Governor I Mike King, Executive Director I Virginia Brannon, Director # • 1876' <br />