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~ III IIIIIIIIIIIIIIII ~~3IlL ~! 1992 DI~'ISiON ~~,F MINERALS & GEO~OG~~ LIMITED IMPACT OPERATION (110(2)) APPLICATION FORM The Application fora Limited Impact Operation Reclamation Permit contains three major parts: (1) the Application Fonn, (2) the Application Exhibits A-F, and (3) the application fee. When you submit your Application, be sure to include two signed copies of the Application Forth, two copies of Exhibits A-F, and a check for the app ication fee described under (4) below. To expedite processing, please provide the information in the format and order described in this form. 5(C . L~; ~ GENERAL OPERATION INFORMATION Type or print clearly, in the space provided, all information described below. 1. Applicant/Operator Name: Shalako International. Inc. 2. Operation Name (Pit, mine or site name): J1~~~,,, ~Qa., ~~,~ ~i 3. Application type: Limited Impact Operation (110).` ~J 4. Application Fee for Permitted Acreage* g,6 permitted acres. (E10 x (affected acres) + 525.00).* Note permitted acreage and application fee and attach a check for this amount when you file. 125.00 application fee. 5. Substance(s) to be mined (e.g., gold/silver/gravel): Cola /silver 6. Owners(s) of Substance to be Mined (check applicable box (s )): x Private _ State _ Federal _ Indian 7. Owner(s) of Record of Affected Land (check applicable box (s )): x Private _ State _ Federal _ Indian 8. ,Type of Mining Operation (check applicable box (s )): _ Surface ~ Underground _ In-situ 9. Location Information. The center of the area where the majority of mining will occur lies in: COUNTY: L Plat PRINCIPLE ER D A c ec one 6th (Colorado) TOWNSHIP (write number and check direction): T 36 RANGE (write number and check direction): R 11 SECTION (write number): S QUARTER SECTION (check one): QUARTER/QUARTER SECTION (check one): ~ NE 10th (New Mexico) Ute X North South East x West ~ NW SE _ SW NW SE SW GENERAL DESCRIPTION: (miles and direction 4 Miles North of Hesperus from nearest town and approximate elevation) * If the operator is a unit of State or county government, an application fee is not required. A fraction of an acre must be counted as one acre for fee calculation.