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s~ STATE OF COLORADO DIVISION OF MINERALS AND GEOLOGY Department of Natural Resources 1313 Sherman St., Room 215 RE Denver, Colorado 80203 ~~'VED Phone: (303186&3567 CONSTRUCTION MATERIALS FAX: (303) 832-8106 JU~ / LIlKITED Il1IPACT (110) OPERATIOpN~~~~~ ~' ,~ RECLAMATION PERMIT APPLICATION FORl1)f Mineralse~d~ep(ogy CHECK ONE: There is a File Number Already Assigned to this Operation Permit # M -_ ~ _ (Please reference the file number currently assigned to this operation) x New Application (Rule 1.4.5) Amendment Application (Rule 1.10) Copvereion Application (Rule 1.11) Permit # M - -_ (provide for Amendments and Conversions of existing permits) COLORADO DIVISION OF MINERALS GEOLOGY RECLANATION•NINING SAFETY•EClFNCE Bill ovens Governor Greg E. Wakher Executive DireROr Ronald W. Cattany DiNSion Dimcim Natural Resource Trustee The applicationforaConstructionMaterialsLimitedlmpact(I10)OperationReclemationPenuitcpntainsthrcemajorparts: (1)theapplication form; (2) Exhibits A-J, Exhibit L, Addendum I, any sections of Exhibit 6.5 and Geotechnlical Stability Exhibit, as required by the Office, and outlined in Rules b.l, 6.2, 6.3, 6.5, and 1.b.2(1)(b); and (3) Ule application fee. When you submit your application, be sure to include one (1) complete sieved and notarized IVORY ORIGINAL and one (1) copy ofthe completed I~ application form, two (2) copies of Exhibits A-J, Exhibi[ L, Addendum 1, and appropriate sections of 6.5 (Geotechnical Stabihty Exhibit), as required, and a check for the application fee described under (4} below. Exhibits should IOT be bound or in a 3-ring binder; maps should Ue folded to 81/2" X 1 I" or 8 1 /2"X 14" size. To expedite processing, please provide the information in the format and order described in this form. GENERAL OPERATION INFORMATION Type or prbtt clearly, in the apace provided, ALL unformation described below, 1. ApplicanUoceratororcompanyname(nametobepsedonpermk): Phillips County r/ 1.1 Type of organization (corporation,partaelship,etc.): Government 1.2 1.2 I.RS. TaxID No. or Social SectniryNumber: R4-6090793 Z. Operation name foil, mine or site pameh: Raf ert Pit ..~ 3. Permitted acreage (pew or erristip¢ able]: 9.9 permitted acres 3.1 Change in acreage (+) 0 acres 3.2 Total Acreage in Permit Area 9.9 acres 4. Fees: 4. ] New Application: t 0 4.00 application fee Amendment Fee (C.RS. 34-32.5-125(II}): 719.00 application fee 4.2 Conversion Fee (from 1 l Od to 110 $875.00 conversion fee (Rule 1.11.2(2)) 5. Primary commoditie(s) to be mined: Gravel Sand 5.1 Incidental commoditie(s) to be mined: 1. / lbsffons/vr 2. / lbs/fons/vr 3. / lbs/Tons/vr 4. / Ibs/I'ons/vr 5. / 1bs/Tons/vr 5.2 Anticipatedetxluseofprimarycommoditie(s)tobemined: Road Qravel and base material Anticipated ead use of incidental commoditie(s) to be mined: N/A Office of Office of Colorado Mined Land Reclamation Active and Inattive Mines Geological SurLt;