MICHIGAN DEPARTMENT OF ENVIRONMENT, GREAT LAKES, AND ENERGY OIL, GAS, AND MINERALS DIVISION

Part 632 Nonferrous Metallic Mine Financial Assurance SummaryBy authority of Part 632 of Act 451 PA 1994, as amended. Non-submission and/or falsification of this information may result in fines and/or imprisonment.

This is a Microsoft Office Word form. The gray ‘form fill-in boxes’ change to accept what is entered.

Name of applicant or permittee      !Mine or beneficiation facility      

Location County       Township       Range       Section      Name of Authorized representative      

Title      

E-mail      

Telephone (include area code)      

Amount of assurance instrument      

Address 1      

Address 2 (if needed)      

City       State       Postal Code      Check to indicate which instrument or instruments apply. Amount (in USD)

Refer to appropriate Part 632 rules for additional details and information

Trust fund or escrow account, cf. Rule 425.303; $       Surety bond, cf. Rule 425.304 $       Irrevocable letter of credit, cf. Rule 425.305 $       Certificate of deposit, cf. Rule 425.306 $       Statement of financial responsibility, cf. Rule 425.307 $       other assurance instrument,

prior approval by the department required.$      

Total amount of financial assurance in US dollars $      

5. Signature, Title, DateCERTIFICATION “I state that I am authorized by said applicant. This application was prepared under my supervision and direction. The facts stated herein are true, accurate and complete to the best of my knowledge.”

EQP 7203 (05/2019)