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<br />STATE O~ COLORADO <br />DIVISION OF MINERALS AND GEOLOGY <br />Deparlmene of Natural Resources <br />I J l J Sherman St., Room 215 <br />Denver, Colorado 80203 <br />Phone: (303) 866-3567 <br />FAX: 13031 832.8106 <br />AVS Annual Review <br />Inspection Worksheet <br />Date Q <br />Mine Name(Permit Number /Qo a.-t`4+ ~'o-r,. t~ l~o~ ~ l n1jK e <br />Inspector Signature <br />Based on your ON-SITE Observation, please answer the following: <br />~~ <br />DIVISION O F <br />MINERALS <br />GEOLOGY <br />REC LA MA710M <br />MINING•SAFETY <br />Bill Owens <br />Governor <br />Greg E. Walther <br />faetuuse Duecror <br />Michael B. long <br />Divivan Director <br />I) Mine ID sign <br />a) Permittee ~QcJ~2r~io~n ~~ `o. <br />b) Operator ~~'~P+'I.ow> ~t ~ ~. <br />o s-OOY ~! ~s.~,u ~,,,.~ <br />c} MSHA ID (not required to be on sign) <br />2) Direct inquiry (of persons on the site) <br />a) Permittee J~dwe~L-4a,...Ce4 ~Co...,~.an~. <br />b) Operator por„lolcr~o.•.~ Ca a / G..,,,w~~ <br />c) MS13AID nr-03of2 ~,c!b ~~iT'L <br />~i~P.,cp Ran. <br />~` 3) Is ownership/control information for Permittee and operator note rn field consistent with <br />what is listed in the person application? Yes No <br />If No, what is in conflict <br />PG c B.(.~ cQ,-s wQ~~c~y r__ was _~.d.~,t~c~/ Pfx `[~f ~ i h <br />arr-oc~~l}'b.1 ~,-r {'~i~~!m~'?~'/~cct_cc.,.ri / if/d. 3~ cJ~~Z.4 dal <br /> <br />aZf`a ~e.a~ <br />1.'J >< if <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 determine whether officer/controller <br />information is complete and accurate in A VS. 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 />