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TATE OF COLORADO <br />DIVISION OF MINERALS AND GEOLOGY RECEIVED <br />Department of Natural Resources <br />1313 Sherman St., Room 215 AUG i 3 2002 ~ <br />Denver, Colorado 802n3 D I v 15 1 0 N O E I <br />Phone: 1303) 866-3567 MINERALS <br />Fqx: t3o3> a3z-alo6 i)ivisien of Minerals and Geofagy G E O L O G YI <br />FILE COPY CONSTRUCTION MATERIALS MININGMSq FIOY <br />LIMITED IMPACT (110) OPERATION <br />fOR SCANN/N~ECLAMATION PERMIT APPLICATION FORM Gnlv~nar 5 <br />Greg E. Walther <br />Executive Director <br />~~ - ~zaa a - ~ ~~ ~ Michael B. Long <br />D"v"ision Director <br />CHECK ONE: New Application (Rule 1.4) Conversion Application (Rule 1 ~ .1 <br />Amendment Application (C.R.S. 34-32.5-110) <br />Permit # vI -_ _ _ (provide for Amendments and Conversions of existing permits) <br />The application for a Construction Materials Limited Impact (110) Operation Reclamation Permit contains three major pazts: (1) the application form; <br />(2) Exhibits A-1, Exhibit L, Addendum 1, any sections of Exhibit 6.5 and Geo[echnical Stability Exhibit, as required by the OfSce, and outlined in Rules <br />6.1, 6.2, 6.3, 6.5, and 1.6.2(1)(b); and (3) the applicaton fee, When you submit your application, be sure to include one (1) cot~lete sieved and <br />notarized IVORY ORIGINAL and one (1) copy of the completed Ivorv application form, two (2) copies of Exhibits A-J, Exhibit L, Addendum 1, and <br />appropriate sections of 6.5 (Geotechnical Stability Exhibit), as required, and a check for the application fee described under (4) below. Exhibits should <br />NOT be bound or in a 3-ring binder; maps should be folded to 8 1R" X 1 I " or 8 1 R" X 14" size. To expedite processing, please provide the information <br />in the format and order described in [his form. <br />GENERAL OPERATION INFORMATION <br />Type or print clearly, in the space provided, ALL information described below. <br />AHHlicanVonerator or comoanv name (name to be used on Hermit): <br />1.1 <br />1.2 <br />2. <br />3. <br />4. <br />Type of organization (corporation, paztnership, etc.): <br />I.R.S. Tax ID No. or Social Security Number: <br />Operation name (pit, mine or site name): <br />Permitted acrease (new or existine site): <br />3.1 Change in acreage (+) <br />Total Acreage in Permit Area <br />Fees: <br />4.1 New Applicafion: <br />Amendment Fee (C.R.S. 34-32.5-125(II)): <br />4.2 Conversion Fee (from 110d to 110 875.00 conversion fee (Rule 1.11.2(2)) <br />5. Primary commoditie(s) to be mined: (.~1t~/~- <br />..-,~ <br />n acres <br />/'~"` acres <br />$1.094.00 application fee <br />719.00 application fee <br />5.1 Incidental commoditie(s) to be mined: 1. / lbs/I'ons/vr 2. / Ibs/fons/vr 3. / lbs/Tons/vr <br />4. / lbs/I'ons/vr 5. <br />5.2 Anticipated end use of primazy commoditie(s) to be mined: _ <br />5.3 Anticipated end use of incidental commoditie(s) to be mined: <br />permitted acres <br />--~-~.!> <br />