Application for License to Surface Mine

MARYLANDDEPARTMENTOFTHEENVIRONMENT

LandManagementAdministration•MiningProgram

P.O.Box1417•Baltimore,Maryland21203-2057

410-537-3557•800-633-6101x3557•

INSTRUCTIONS FOR LICENSE TO SURFACE MINE APPLICATION

Printortyperesponsestoallquestions!

Theapplicationshallbeaccompaniedbya$300filingfeefororiginallicenseora$150filingfeeforlicenserenewal.PaymentshallbemadebycheckormoneyordermadepayabletotheMarylandDepartmentoftheEnvironment.Refundsoffeeswillnotbemadeiftheapplicationisrefusedordenied.

Checkappropriateboxspecifyingifapplicationisoriginalorrenewal.

Item(1)Applicant’snameandaddressshallbethesameastheprincipleoperator’s.

ProvideWorker’sCompensationInsuranceNumber.

Checkappropriateboxindicatingwhetherapplicantisanindividual,partnership,corporationorLimitedLiabilityCorporation.

ProvideFederalIdentificationNumberorSocialSecurityNumber.(Willremainconfidential)Item(2) ProvidedatethecorporationwasregisteredinMarylandwiththeDepartmentof

AssessmentandTaxation

Item(3)Listonlythoseindividualsincludedasprinciples.Ifapplicantissoleowner,pleaseindicate.

Listtheregisteredagent.

Item(4)Completetherequiredinformationandcheckappropriateboxes.Ifquestiondoesnotapplyindicate“N.A.”

Item(5)Checkappropriatebox.If“YES”,explain.Signandreturnapplicationto:

MarylandDepartmentoftheEnvironment

Minerals,Oil,GasDivision

P.O.Box1417

Baltimore,Maryland21203-2057

Ifadditionalspaceisneeded,useaplainsheetofpaperandattachtoapplication.

APPLICATION FOR LICENSE TO SURFACE MINE

InOfficeUse: Status:EXPDT:

Y/N: LBTY:

Checkone: / []Original / [ ] Renewal / SourceCode5671
($300) / ($150) / PCA 13752

IncompliancewithprovisionsofTitle15,Subtitle807,oftheAnnotatedCodeofMarylandandapplicableregulationsoftheLandManagementAdministration,applicationisherebymadeforalicensetosurfacemineformineralsotherthancoal.

1) / ApplicantName:
Address:

Telephone:Fax:

a)Worker’sCompensationInsuranceNumber:

Checkone:[]Individual[]Partnership[]Corporation[]LimitedLiabilityCorporation

b)FederalIdentificationNumberorSocialSecurityNumber:

2)Ifoperatorisacorporation,iscorporationregisteredtodobusinessinMaryland?

[] YES[]NO

DateRegistered:

3)Ifapplicantisapartnership,listallpartnerseitherfullorlimitedandaddresses.Inthecaseofacorporation,listregisteredagent,allprincipleofficers,directors,andaddresses.

NameTitleAddress

,RegisteredAgent

4)Wereanyoftheabove-named(initem#3)everpreviouslyengagedinsurfaceminingasanindividual,partner,orofficerofacorporationandifso,wassuchconductedunderanamedifferentthanthatofapplicant?

[] YES[]NO

NameofIndividual:

Nameunderwhichoperationwasconducted:

Dateoperationwasconducted:

Aretherepresentlyanyoutstandingviolationsagainstapplicant?[ ]YES[]NO

Hastherebeenanybondforfeituresinanystatebyapplicantorbyanymember(s)ofthecorporationorpartnership?

[] YES[]NO

IfYES,attachdetailsonaseparatesheet.

5)Haveyoupreviouslybeenlicensedasasurfacemineoperatorandfailedtorenewyourlicense?[] YES[]NO

IfYES,explain:

Iherebycertifythatallinformationcontainedinthisapplicationistrueandcorrecttothebestofmyknowledgeandthatanywillfulmisrepresentationoffactswillresultinthesuspension/revocationyourpermit.

BysubmissionofthisapplicationIherebyaccepttheresponsibilityofconductingtheoperationinaccordancewiththeapproveddrillingandoperationspermit,plans,mapsandanyoccupyingdocuments.

TypewrittennameandtitleOriginalSignatureDate

EmailAddress

This Notice is provided pursuant to § 10-624 of the State Government Article of the Maryland Code. The personal information requested on this form is intended to be used in processing your application. Failure to provide the information requested may result in your application not being processed. You have the right to inspect, amend, or correct this form. The Maryland Department of the Environment (“MDE”) is a public agency and subject to the Maryland Public Information Act (Md. Code Ann., State Gov't §§ 10-601, et seq.). This form may be made available on the Internet via MDE’s website and is subject to inspection or copying, in whole or in part, by the public and other governmental agencies, if not protected by federal or State law.