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STATE OF COLORADO <br />DIVISION OF RECLAMATION, MINING AND SAFETY M _ 2— r i -3 - C� <br />Department of Natural Resources <br />Denver, Sherman Colorado 80203 215 RECEIVS0 <br />Den <br />Phone (303) 866.3567 <br />FAX: (303) 832.8106 <br />SEP 0 4 2013 <br />LIMITED IMPACT OPERATION (110(aVf*n of Reol <br />RECLAMATION PERMIT wing On, <br />APPLICATION FORM <br />CHECK ONE: 9 New Application (Rule 1.4) 0 Conversion Application (Rule 1.11) <br />Permit # M- (provide for conversions of existing permits) <br />COLORADO <br />DIVISION OF <br />RECLAMATION <br />MINING <br />SAFETY <br />The application for a Limited Impact Designated Mining Operation Reclamation Permit contains three major.parts: (1) the application <br />form; (2) Exhibits A -J, any required sections of Exhibit S and Geotechnical Stability Exhibit, as required by the Office, and outlined in <br />Rules 6.1, 6.2, 6.3, 6.4.19 and 6.5; and (3) the application fee. When you submit your application, be sure to include one (1) si&Md an <br />notarized original and one (1) copy of the application form, two (2) copies of Exhibits A -J, appropriate sections of 6.4.19 Exhibit S and 6.5 <br />(Geotechnical Stability Exhibit), as required, and a check for the application fee described under (4) below. Exhibits should not be bound <br />or in a 3 -ring binder; maps should be folded to 8 1/2" X I 1 " or 8 112" X 14" size. To expedite processing, please provide the information <br />in the format and order described in this form. <br />GENERAL OPERATION INFORMATION <br />Type or print clearly, in the space provided, alt information described below <br />1. Applicantloperator or company name (name to be used on the permit): �Ga� 011a r iG e u ma /1 <br />1.1 Type of organization (corporation, partnership, etc.): <br />2. Operation name (phi, mine or site name): A-a a I i S : ii P �g„ la I <br />3. Permitted acreage (new or existing site): J permitted acres <br />4. Fees: <br />4.1 New Application application fee <br />4.2 Amendment Application (from 1.10(2)) <br />4.3 Conversion Fee (from 110d to 110(2), (Rule 1.11.2(2)) - conversion fee <br />5. Primary commodities) to be mined: <br />6. <br />7. <br />Name of owner to the surface of affected land: iCrt t �4'� �2t ►J� 1� T}Pi ���Bak Bpp rig or 5( , <br />Name of owner to the subsurface ri2bts of affected land: �� ln►i �M a it t�. Z 509 7 <br />7`voe of mining operation: S Surface El Underground F-1 In -situ <br />Office of Office of <br />Mined land Reclamation Denver • Grand junction - Durango Active and Inactive Mines <br />