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.~ <br />DIVISION OP MINERALS AND GEOLOGY <br />Department of Natural Resources <br />7373 Sherman St., Room 275 <br />Denver, Colorado 80203 <br />Phone: (303) 866-3567 <br />FAX: (303) 832-8106 <br />~M-~oa~ -os'~ <br />STATE OF COLORADO <br /> <br />CONSTRUCT'IONMATERiAZS(®AaiMlaeral$aadGeologlr <br />LIMITED IIVIPAI:T (110) OPERATION <br />RECLAMATION PERMiT APPLICATION FORM <br />CHECK ONE: <br />There is a Fr7e Nnmber Already Assigned to this Operation <br />COLORADO <br />DIVISION O F <br />MIDI SRALS <br />GEOLOGY <br />REC LAMATION•MINING <br />SAf ETY•SCIENCE <br />Bill Owens <br />Governor <br />Russell George <br />Executive Director <br />Ronald W. Cottony <br />Division DlrectOr <br />Natural Resource Trustee <br />Permit # M -` _ _ (Please reference the file number currently assigr7ed to this operation) <br />X New Application (Rule ].4.5) Amendment Application (Rule I.10) <br />Conversion Application (Rule 1.11) <br />Permit # M -, -_ (provide for Amendments and Conversions of existing permits) <br />The application for a Construction Materials Limited Impact (110}Operation Reclamation Permit eontainstl7rce major pacts: (I) the application <br />form; (2) Exhibits A-J, Exhibit L, Addendum 1, any sections of Exhibit 6.5 and Geotechnical Stability Exhibit, as required by the Office, and <br />outlined in Rules 6.1, 6.2, 6.3, 6.5, and 1.6.2(1)(b); and (3) the application fee. When you submit your application, be sure to include one <br />(1) complete si7med sad notarized ORIGINAL and one (7) copy ofthe completed application form, two (2) copies ofExhibits A-J, Exhibit L, <br />Addendum 1, and appropriate sections of 6.5 (Geotechnical Stability Exhibit), as required, and a check for the application fee described under <br />(4) below. Exhibits should NOT be bound or in a 3-ring binder, maps should be folded to 8 112" X 11" or 8 1 /2" X 14" size. To expedite <br />processing, please provide the information in the format and order descnbed in tlis form <br />GENERAL OPERATION INFORMATION <br />Type or print clearly, in the apace provided, ALL information described below. <br /> I / <br />1. A.on N C 0 LN <br />licantlooerator or comoanv name (name to be used on cermht~: L COUNTY I <br /> 1.1 Type oforganuation(corporation,partnership,etc.): GOVERNMENT <br /> 1.2 I.RS.TaxIDNo.orSocialSecurityNumber $ <br />2. Oce rationname(oit.mhneoraitenamel: ANDERSEN FARMS <br />3. Permitted acreage (new or e7risthn¢ skel: 7 . 6 permitted acres <br /> 3.1 Change in acreage (+) acres <br /> 3.2 Total Acreage in Permit Area ~ • 6 acres <br />4. ~: <br /> 4.1 New Application: 10$ .94.00 application fee <br /> Amendment Fee(C.RS.34-32.5-125(IT)): 7$ 19.00 application fee <br /> 4.2 Conversion Fee {from I l Od to 110 875.00 conversion fee (Rule 1.11.2(2)) <br />5. Pr®arvrnmmoditie(al to be mined: SAND GRAVEL <br />5.1 Incidental commoditie(s) to be miuecl: l N A / lbslTons/w' 2. / lbs/Tons/vr 3. / lbs/fons/vr <br />4. / lbsll'ons/vr 5. / lbsll'onslyr <br />5.2 Anticipated end useofprimarycommoditie(s}tobe mined: ROAD MAINTENANCE <br />Anticipated end use of incidental commoditie(s) to be mined: N A <br />Office of Office of Colorado <br />Mined Land Reclamation Active and Inactive Mines Geological Survey <br />