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<br />STATE OF COLORADO <br />DIVISION OF MINERALS AND GEOLOGY <br />Depanmenl of Natural Resources <br />1317 Sherman 51.. Roan 215 <br />Dcnver, Colorado 80203 <br />Phone: 1303) 8661567 <br />FA%:130 31 83 2-8106 <br />Date ~n~/ <br />Av8 Annual Review <br />inspection Worksheet <br />Hine Name/Permit Number C- <br />~~ <br />DEPARTMENT OF <br />NATURAL <br />RESOURCES <br />Roy Romer <br />inspector Signature cnve.ror <br />dames S. lochhead <br />Based on your oa-site observation, please answer the followi>ft~""~D1eior <br />Mahael B. Long <br />1) Mine ID sign olv lslnn oueOOr <br />a) Permittee ~,~~~p..,,,,""~~s{~~~~(,~~~~/~j//)p ~. <br />b) Operator p(;(~'{-I¢ / <br />c) MSHA ID <br />2) Direct inquiry (of persons on the site )n` <br />a) Permittee ~ '~ ~1~ l-(1U-f mIYN{w~ <br />b) Operator ~~CIA'YIPJ C <br />c) MSHA ID ~-QQ~~j <br />3) Is ownership/control info ation for permittee and operator <br />noted in field consiate 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 />