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ELIBERATIVE g~~i <br />PROCESS COPY <br />DISCARD AFTER USE RECEIVED <br />CONSTRUCTION MATERIALS SEP 3.0 ~~2004 <br />REGULAR (112) OPERATION `/ <br />RECLAMATION PERMIT APPLICATION FORM Division of Minerals and Ceab~ <br />CHECK ONE: There is a File Numb/er Aheady Assigned to this Operation <br />Permit # M -19 _ 88 -093" (Please reference the file number currently assigned [o this operation) <br />New Application (Rule 1.4.5) X Amendment Application (Rule L 10) <br />Conversion Application (Rule 1.11) <br />Permit # M - 19 _ 88 _ 09 3 (provide for Amendments and Conversions of existing pemuts) <br />The application for a Constmetion Materials Regulaz 112 Operation Reclamation Pemut contains three major parts: (I) the application <br />form; (2) Exhibits A-S, Addendum 1, any sections of Exhibit 6.5 (Geotechnical Stability Exhibit; and (3) the application fee. When you <br />submit your application, be sure to include one (1) comole[e signed and notarized ORIGINAL and one (1) copy of the completed <br />application form, two (2) copies of Exhibits A-S, Addendum 1, appropriate sections of 6.5 (Geotechnical Stability Exhibit, and a check for <br />[Ire application fee described under Section (4) below. Exhtbits should NOT be bound or in a 3-ring binder, maps should be folded to <br />8 1/2" X 11" or 8 1/2" X 14" size. To expedite processing, please provide the information in the format and order descnbed in this form <br />GENERAL OPERATION INFORMATION <br />Type or print clearly, in the space provided, ALL information requested below. <br />1. AonticanUooeratar or camoanv name (name to be used on Prrmit): Fremont Paving & Redi Mix, Inc. `~ <br />1.1 Type of organization (corporation, partnership, etc.): Corporation <br />1.2 I.R.S. Tax I.D. No. or Social Secnrity Number. <br />2. Oceration name (oit mine or site Hamel: Fremont PdVing & Redl Mix Pit <br />3. Permitted acreage (new or existine site): <br />3.1 Change in acreage (+) <br />3.2 Total acreage is Permit area <br />22.5 permitted acres <br />acres <br />22.5 acres <br />4. Fees: <br />4.1 New Application $2.344.00 application fee <br />4.2 New Quany Application $2,906.00 quarty application <br />4.4 Amendment Fee $1,938.00 amendment fee <br />4.5 Conversion to 112 operation (set by statute) $2.344.00 conversion fee <br />5. Primary commoditie(s) to be mined: Sand Gravel <br />5.1 Incidental commoditie(s) to be mined: I. N /A - Ibsrl'ons/yr 2. / Ibs/Tons/vr <br /> 3. / Ibs/Tons/vr 4. / Ibs/Tons/vr 5. / Ibs/7'ons/yr <br />5.2 Anticipated end use of primary commoditie(s)tobemined: Construction as: QreQate <br />5.3 Anticipated end use of incidental commoditie(s) to be mined: N/A <br />