2018-12-28_REVISION - C1980004 (3)

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APPLICATION FORM FOR A REVISION TO A COAL MINING AND RECLAMATION PERMIT This form must be completed and submitted with all requests for minor revisions, as defined in Rule 1.04(73), technical revisions, as defined in Rule 1.04(136), and permit revisions, as defined in Rule 1.04(90). All revisions are to address the requirements of Rule 2.08.4. Three (3) copies of the revision, including maps, must be submitted in order for it to be complete. All revisions are to be formatted so they can be inserted into the permit to replace the revised sections, maps, tables and/or figures, with a revised table of contents, if necessary. The revision submittal date should be printed in the lower right corner of each revision page. A cover letter to the revision should explain the nature of the revision and reference the specific permit sections being revised. For federal mines, a copy of the revision application must be submitted to all agencies on the federal mailing list (except OSM) at the same time the application is submitted to the Division, and proof of distribution must be submitted to the Division along with the application. Copies of revision pages modified during the review process must be distributed in the same manner, along with proof of distribution. Proof of distribution must be submitted prior to implementation of the revision. Permit No.: C - - Date: / / Permittee: Street: City: State: Zip Code: - Brief Description of Revision: Public Notice Attached: Yes No (Required for PRs and TRs) Bond Increase: Yes No Federal Non-Federal Mine Proposed Change in: Permit Area - Surface Ownership - Disturbed (+/-) . Acres Private Land (+/-) . Acres Permit (+/-) . Acres Federal Land (+/-) . Acres Affected (+/-) . Acres State Land (+/-) . Acres Mineral Ownership - Mineral Private (+/-) .Acres Mineral State (+/-) . Acres Mineral Federal (+/-) . Acres