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STATE OF COLORADO <br />DIVISION OF MINERALS AND GEOLOGY <br />Depanmenl of Natural Resources <br />1313 Sherman 51., Room 215 AV8 AIIIInal R@View <br />Denver, Colorado 80203 <br />Phone: 13031866-3567 Inspection Worksheet <br />f A%: 11071 832-8106 <br />Date /~ Zp <br />Mine Name/Permit Number C-9T~-D a' ~~~~ <br />Inspector Signature <br />Based on your on-site observation, please answer the <br />1) Hine ID sign /~~n <br />a) Permittee ~~~,CL (~S~Y L47 <br />b) Operator (~~- <br />c) MSHA ID {~~~- <br />2) <br />3) <br />Direct inquiry <br />a) Permittee <br />b) Operator <br />c) MSHA ID <br />(of eraons on the site) <br />~~ ~~~- <br />~~ <br />~~ <br />DEPA[ZTMFN[' OF <br />NATURAL <br />a~souticFs <br />RoY Romer <br />Goverror <br />dames 5. lochhead <br />fol lowi~i~"i"` Direeror <br />Mkhael B Long <br />p iv ision Director <br />Is ownership/control info ation for permittee and operator <br />noted in field consist t with what is listed in the permit <br />application? Yes No <br />If No, what is in conflict? <br />DMG is required to verify this information as specified in the AVS <br />MOU if the permitting action was approved subsequently to the MOU <br />(renewal, transfers and revisions). Annually as long as coal <br />extraction from the site has not been completed, DMG must determine <br />whether officer/controller information is complete and accurate in <br />AVS. In making the determination of complete and accurate <br />information, on-site observations and direct inquiry of persons on <br />the site is necessary. The information on this form will be <br />verified with AML, MSHA, and EIA information in AVS. Please return <br />the form to Erica Crosby to be verified in the AVS. <br />c:\avs\annual •_ <br />