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~lV~ - ~ o c~5- d/ ~ <br />R~EIVED <br />CONSTRUCTION MATERIALS <br />REGULAR (112) OPERATION , / / LIAR ~ 4 ~OQ~ <br />RECLAMATION PERMIT APPLICATION FORM° <br />Oirisiga.gt Miaoral8 and GeoloOY <br />CHECK ONE: There is a File Number Already Assigned to this Operation <br />Permit # M -_ -_ (Please reference the file number 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 Regular 112 Operation Reclamation Pertnit contains three major parts: (1) 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) comuletc sieved 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 (Geo[echnical Stability Exhibit, and a check for <br />the application fee described under Section (4) below. Exhibits should NOT be bound or in a 3-ring binder; maps should be folded to <br />8 I/2" X 11" or 8 1/2" X 14" size. To expedite processing, please provide the information in the format and order described in this form. <br />GENERAL OPERATION INFORMATION <br />Tvpe or print clearly, in the space provided, ALL information requested below. '/ <br />1. ApplicanUonerator or comoanv name (name to be used on perroit~: p G <br />1. ] Type of organization (corporation, partnership, etc.): ^^~~ O WN ~ 2 <br />1.2 I.R.S. Tax I.D. No. or Social Security Number:/~ p~,t.~t q- '--~ ~tJ ° `~~ ~~ <br />2. OaeraNon name (ait, mine or site name): (if /\Ry / / ~ ~PT <br />3. Permitted acreage (new or existing site): _~ Permitted acres <br />3.1 Change in acreage (+) acres <br />3.2 Total acreage in Permit azea _ 7~ acres <br />4. Fees <br />4.1 New Application $2.344.00 application fee <br />4.2 New Quarry Application $2.906.00 quarry application <br />4.4 Amendment Fee $1 938.00 amendment fcc <br />45 Conversion to ] 12 operation (set by statute) $2.344.00 conversion fee <br /> <br />~. Primary commoditie(s) to be mined: ~ l.o ~,Q(~ <br />S.l Incidental commoditie(s) to be mined: 1. ~ - Ibs/Tons/ r 2. / lbs/Tons/vr <br /> 3. / lbs/Tons/vr 4. / ]bs/Tons/y <br />r <br />5. / Ibs/Tons/ r <br /> <br />5.2 ~ <br />l-/~ <br />Anticipated end use of primary commoditie(s) to be mined: ~~S t /~Ll ~ <br />~~ <br />F! /' L <br />~1~9~4/["~E <br />d.3 Anticipated end use of incidentai commoditie(s) to be mined: ~ / <br />/ <br />T <br />