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I,lIVISION OF RECLAMATION, MINING AND SAFETY <br />Department of Natural Resources <br />1313 Sherman St., Room 215 <br />Denver, Colorado 84203 <br />Phone: (303) 866 -3567 <br />FAX: (303) 832 -8106 <br />i �a-" <br />Request for the DRMS <br />I)- 1/7� - /k( <br />STATE OF COLORADO <br />Document Imaging CD/DVD <br />REQUEST FORM <br />nt images on the <br />2% /rev ? -,((,/. <br />4,5-- <br />,flowing DRMS Permit file(s) <br />4) <br />A <br />'COLORADO <br />j D I V I S ION OF <br />I RECLAMATION <br />r' MINING <br />G' I_ SAFETY <br />L/ <br />J <br />/ <br />The DRMS document images ca , ' to either a CD or a DVD. Please check one below and return a /�'h3 <br />this form with your payment to DBMS. if a CD is requested and the permit is too large for a CD, you will be called. <br />CD @ $5.00 per disk z DVD @ $20.00 per disk <br />Please check if you want a copy of the Directions for Use of CD /DVD <br />The Permit File document images can be viewed in the reception area of the DRMS office, online at www.nnning. state.co.us, or <br />they can be purchased on a CD or DVD. The CD/DVD purchase cost covers the time and labor of making the CD/DVD. <br />- • <br />4. - <br />5. •. . ' •• •r �• •• <br />DRMS cannot provide computer related support. <br />Disclaimer: <br />The Colorado Division of Reclamation, Mining and Safety (DRMS) is not responsible and shall not be liable to the user fc <br />damages of any kind arising out of the use of data or information provided by the DRMS, including the installation of the data c <br />information, its use, or the results obtained from its use. Any data or information provided by the DRSM is provided "as is <br />without warranty of any kind, either express or implied, including, but not limited to, the implied warranties of merchantabilit <br />and fitness for a particular purpose. Data or information provided by the DRMS shall be used and relied upon only at the user' <br />sole risk, and the user agrees to indemnify and hold harmless the DRMS, its officials, officers and employees from any liabilit <br />arising out of the use of the data/information provided. <br />Customer Mailing and Contact Information: <br />Print Name: L�A O c l- L i t �, <br />Company: <br />1( <br />Address: k, C' <br />T <br />Phone: 3 �' _3 '� 70 - 10)4 -A�u <br />Signature: <br />Office of <br />Mined Land Reclamation Denver • Grand junction • Durango <br />DBMS use only <br />CD/DVD created and <br />tested by: <br />e, �L{ <br />Date: 4a / <br />Office of <br />Active and Inactive Mines <br />