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~M- boas - or,Z, <br />STATE OF COLORADO <br />DIVISION OF MINERALS AND GEOLOGY / <br />Department of Natural Resources r <br />1313 Sherman St., Room 215 <br />Denver, Colorado 80203 <br />Phone: (303) 8663167 <br />FAX: (3031 83 2-81 06 <br />, .... ., r ......v) <br />ivisinn nt Minetn4s& n?olnrrs; <br />CONSTRUCTION MATERIALS <br />LIMITED IMPACT (110) OPERATION <br />RECLAMATION PERMIT APPLICATION FORM <br />CHECK ONE: <br />There is a File Number Already Aasigped to this Operation <br />J COLORADO <br />DIV [SIGN OF <br />MIAiE~RALS <br />GEOLOGY <br />0.EC LAM ATION~NINING <br />$AFETY•SC IENCE <br />Bill Owens <br />Governor <br />Russell George <br />Executive DireROr <br />Ronald W. Cattany <br />Division DireROr <br />Natural Resource Trustee <br />Permit # ~-_ _ _ (Please reference the file nlnnber currently assigned to this operation) <br />New Application (Rule 1.4.5) Amendment Application (Rule 1.10) <br />Conversion Application (Rule 1.1 I ) <br />Permit # M -~ -_ (provide for Amendments and Conversions of existing permits) <br />The application For a Construction Materials Limited Impact (110) Operation Reclamation Permit contains duce majorparts: (1) the application <br />form; (2) Exhibits A-1, Exhibit L, Addendum I ,any sections of Exhibit 6.5 and Geotechtrica! Stability Exhibit, as required by the Office, and <br />outlined in Rules 6.1, 6.2, 6.3, 6.5, and 1.6.2(I)(b); and (3) the application fee. When you submit your application, be sure to include one <br />(1) complete si med and notarized ORIGINAL and one (I) copy of the completed application form, two (2) copies of Exhibits A-1, Exhibit L, <br />Addendum 1, and appropriate sections of 6.5 (Geotechnical Stability Exhibit), as required, and a check for the application fee described tinder <br />(4) below. Exhibits should NOT be bound or in a 3-ring binder; maps s`tould be folded to 8 1/2" X 11" or 8 1/2" X 14" size. To expedite <br />processing, please provide the information iD 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 /> <br />1. <br />App <br />ticanUonerator or company name (name to be used on xrmitl: ~ ~ <br />~ U ~~° f/ C ..i v <br />i Yl ~=, ~fiJ r' -~i ~'j ~_ <br /> 1.1 ~ <br />Type of orgattization (corporation, partnership, etc.): ~/~ ~ C~' i, <br />r r J ~ / F. 1 t7 'v'im <br /> 1.2 I.R.S. Tax ID No. a Social Security Number: <br /> <br />2. <br />Ope / <br />ration name (nit. mine or site namel: r~/(u /E /~ (..~ n71 <br />S ~ 1"LtC~s ~ i n n <br />~i }-- ~'1 <br />3. Permitted acreage thew or eaisting site): _~~ permitted acres <br /> 3.1 Change in acreage (+) acres <br /> 3.2 Total Acreage in Petxnit Area ~'/. Cl acres <br />4. Fees: <br /> 4.1 New Application: $1-094.00 application fee <br /> Amendment Fee(C.R.S.34-32.5-125(II)): $719.00 application fee <br /> 4.2 Conversion Fee (from 1 ] Od to 110 $875.00 con <br />version fee (Rule 1.11.2 (2)) <br />5 f <br />P <br />i <br />di <br />/ <br />' <br />. r mary commo <br />tiefsl to be mined: C ( <br />( <br />( <br /> 5.1 Incidental commoditie(s)tobemined: 1. / ]bslLonslvr 2. ! 1bsrI'ons'vr 3. 1 lbs/fonslvr <br /> 4. ! 16s/Tonslvr 5. 1 lbsll'onslvt <br /> 5.2 Anticipated end use of primary commoditie(s) to be mined: ~ <br />G <br />Y) <br />S ~Y(t LF.~ J O)`L <br /> Anticipated end use of incidental commoditie(s) to be mitred: n <br />, <br />n <br />!Y /JV <br /> <br />Office of Office of Colorado <br />Mined Land Reclamation ARive and Inactive Mlnes Geological Survey <br />