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COLORADO <br /> Division of Reclamation, <br /> Mining and Safety <br /> Department of Natural ReSOLrces <br /> 1313 Sherman Street, Room 215 JAN 0 4 2021 <br /> Denver,CO 80203 <br /> DIVISIv'd Cr ;DECLAMATION <br /> LIMITED IMPACT OPERATION(110(1)) MINING AND SAFETY <br /> RECLAMATION PERMIT <br /> APPLICATION FORM <br /> CHECK ONE: New Application <br /> Permit# M-2017 ..035 (provide for conversions and amendments 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 6.1, <br /> 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 original <br /> and one(1)copy of the application form,two(2)copies of Exhibits A-J,and 6.5(Geotechnical Stability Exhibit),as required,and a check <br /> 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 1/2" X <br /> I I" 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): Miners Mall, LLC <br /> 1.1 Type of organization(corporation,partnership,etc.): Limited Liability Corporation <br /> 2. Operation name(pit,mine or site name): Humming Bird Mine <br /> 3. Permitted acreage(new or existing): (must be 5 acres or less) 1.0 permitted acres <br /> 4. Fees: <br /> 4.1 New Application S288.00 application fee <br /> 5. Primary commoditie(s)to be mined: Amethyst, Fluorite, Copper Mineral Specimens <br /> 6. Name of owner to the surface of affected land: Bureau of Land Management <br /> T Name of owner to the subsurface rights of affected land: Dennis Schneider&Tammey Holbrook <br /> 8. Type of mining operation: _a Surface la Underground OPlacer <br /> of•coo <br /> 1313 Sherman Street, Room 215,Denver,CO 80203 P 303.866.3567 F 303.832.8106 http://mining.state.co.us _ R <br />