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DIVISION OF RECLAMATION, MINING AND SAFETY <br />Department of Natural Resources <br />1313 Sherman St., Room 215 <br />Denver, Colorado 80203 <br />Phone: (303) 866 -3567 <br />FAX: (303) 832 -8106 <br />STATE OF COLORADO <br />AVS Annual Review <br />Inspection Worksheet <br />Date ✓(� X /V <br />Mine Name/Permit Number <br />w��l� C ���d�o� <br />Inspector Signature <br />Based on your ON -SITE Observation, please answer the following: <br />1) Mine ID sign <br />a) Permittee M %w^ h, d ` Cs C, (94y2A1 / (- C C <br />b) Operator 1 fjtAnh � � 1.0 +Vt (AyH''� , �- �-�. <br />C) MSIIA ID ®�� � (not required to be on sign) <br />2) Direct inquiry (of persons on the site) /% <br />a) Permittee N`PVMi f7 (' (tz'v/ �/+��1G1� y �`'C� <br />b) Operator p m"N f -"l P (X./ rawv6n7 L 1,6 c) MSHA ID <br />COLORADO <br />D I V I S I ON OF <br />RECLAMATION <br />MINING <br />SAFETY <br />3) Is ownership /control information for permittee and operator noted in field consistent with <br />what is listed in the permit application? Yes L&_— No <br />If No, what is in conflict? <br />DMG is required to verify this information as specified in the AVS MOU if the permitting action was <br />approved subsequently to the MOU (renewal, transfers and revisions). Annually as long as coal <br />extraction from the site has not been completed, DMG must detennine whether officer /controller <br />information is complete and accurate in AVS. In making the determination of complete and accurate <br />information, on -site observations and direct inquiry of persons on the site is necessary. The information <br />on this form will be verified with AML, MSHA, and EIA information in AVS. Please return the form to <br />Johanna Cramer to be verified in the AVS. <br />Office of Office of <br />Mined Land Reclamation Denver • Grand junction • Durango Active and Inactive Mines <br />