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STATE OF COLORADO <br />n1VISION OF RECLAMATION, MINING AND SAFETY <br />17epartment of Natural Resources <br />1313 Sherman St., Room 215 <br />Dpver, Colorado 80203 p tOv i SOI o N DO <br />Phone: (303) 866 -3567 Document Imaging CD/DVD RECLAMATION <br />FAX: (303) 832 -8106 r` MINING <br />REQUEST FORM — &— <br />SAFETY <br />Request cument images on t he following DRMS Permit file(s): 3) 1 ' l �-�}�� 4) — ZI <br />OQRMdocument images can be copied to either a CD or a DVD. Please check one below and return <br />this form with your payment to DRMS. If a CD is requested and the permit is too large for a CD, you will be called. <br />CD @ $5.00 per disk 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.nuning.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 />2. Ctick 4- to Accept <br />- • <br />4. 0: _ <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 infonnation 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 DBMS, 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: P " f-? T ao L-L( vt S <br />Company: <br />It <br />Address: <br />Po 6 d�( <br />J- Palo S�YUhyo �� gd s <br />Phone: 3 " 5 70 —076A <br />Signature: _7 <br />Office of <br />Mined Land Reclamation Denver • Grand Junction • Durango <br />DRMS use only <br />CD/DVD created and <br />tested by: <br />K,�it� <br />Date: ja / <br />Office of <br />Active and Inactive Mines <br />