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COLORADO DIVISION OF MINERALS AND GEOLOGY <br /> 1313 Sherman Street, Room 215, Denver, Colorado 80203, (303) 866-3567 <br />APPLICATION FORM FOR A REVISION <br />TO A COAL MINING AND RECLAMATION PERMIT <br />This form must be completed and submitted with all requests for minor revisions, as defined in Rule 1.04(73), <br />technical revisions, as defined in Rule 1.04(136), and permit revisions, as defined in Rule 1.04(90). All revisions <br />are to address the requirements of Rule 2.08.4. Three (3) copies of the revision, including maps, must be <br />submitted in order for it to be complete. <br />All revisions are to be formatted so they can be inserted into the permit to replace the revised sections, maps, <br />tables and/or figures, with a revised table of contents, if necessary. The revision submittal date should be printed <br />in the lower right corner of each revision page. A cover letter to the revision should explain the nature of the <br />revision and reference the specific permit sections being revised. <br />For federal mines, a copy of the revision application must be submitted to all agencies on the federal mailing list <br />(except OSM) at the same time the application is submitted to the Division, and proof of distribution must be <br />submitted to the Division along with the application. Copies of revision pages modified during the review process <br />must be distributed in the same manner, along with proof of distribution. Proof of distribution must be submitted <br />prior to implementation of the revision. <br />Permit No.:C - - Date: / / <br />Permittee: <br /> <br />Street: <br /> <br />City: <br />State: Zip Code: - <br />Brief Description of Revision: <br /> <br /> <br /> <br />Public Notice Attached: Yes No (Required for PRs and TRs) <br />Bond Increase: Yes No Federal Non-Federal Mine <br />Proposed Change in: <br />Permit Area - Surface Ownership - <br />Disturbed (+/-) . Acres Private Land (+/-) . Acres <br />Permit (+/-) . Acres Federal Land (+/-) . Acres <br />Affected (+/-) . Acres State Land (+/-) . Acres <br />Mineral Ownership - <br />Mineral Private (+/-) . Acres Mineral State (+/-) . Acres <br />Mineral Federal (+/-) . Acres