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<br />• ' <br />• <br />i l DEPARTh"EKl OF THE INTERIOR <br />0.-wroveabvG40 .' <br />'' 1. GIrP-.au Cne-rc: Er:.. .. - , - <br />.•:.~z`Yl.tentti S1 : <br />J-1~'Q ::t':.t. <br />.: <br />' <br />,~ <br />at5rysb71R08g51 Otfice of Surface Minir)g .'• ... .. <br />, <br />• <br />~~ <br />ERpr.es ez{173t COAL PRODUCTION 'AND RECLAMRTION'FEE REPOR?' ~~"GQ1bc' ~• <br />~"~'"t~h <br />I6~ <br />: <br /> , X , ;f <br />. <br />READ INSTRUCTIONS BEFORE COt:APLETING TH15 FT1Rk/1 ~' . :~.y;,T •' -sE a~.\' <br />)i preprinted information is incorrect or miccmg make eorre[4'ro ru of <br />~ a° '~~ <br />i` :~ <br />~ <br />. <br />. <br />~ <br />;, additions in item 14 only. Do not write il+.it^rl-rs 3-12.;. ~ sue. <br />'~~' <br />1 <br />. <br />, <br />z~r,_I ' <br />2. Mark "X" in the box 3a. State Permit Number : ! <br />.. <br />~ 4. Mlhc Ip'~j6mb1lr+'lla;M`-; <br />a .. 4. ri.: I!'~ <br /> <br />if lust report O <br />~ .. ., r ~ <br />3b. Expuation Date ! .~. <br />, ~' ir' <br />r. r +••~~ ~ ~~ f 5~ + '4 <br /> <br />5. Name of Operator - :Name of Perminee _ ~` <br />.. .S' '° ~.; Ii <br /> '.I ~ <br />.. <br />... n , <br />. - ' ... <br />.. <br /> :: <br />1' <br />Mai ing Address Mailinq~Addrels ~'•t '. "~ - -I''•i,y k r-',: ~~• '~' ' <br />~ <br />~'7, 1Y _ /i~i.l' 1 ~ ~ fl it a'J1f: 1' <br />l ., _' ~1 _ ..ed. <br />r ~i._ .;.. i~~i~•~~L.:>:r_=.'.e}~~.~.'v <br />-" <br />: <br />~ <br />State ZlpCode <br />Fi -~ <br />.. 'I%°t <br />,µ, <br />,~~ci.1_ -.,,":.'. ::~, <br />C?>'y. - - .. <br />°,` !. ~' .~ - <br />° <br />' <br /> , •i <br />.: ~ Jy. .- '•^d- ,:.ate ~.4j.~ee ~i <br />i <br />~ ~ <br /> .. .. „ <br />y:. .. -. <br />;:>.. _~r_s(;.;.,~~..;~: ~ <br />_LOCATION:QF.;~INE`-, ,,'~:::,*, <br />- . <br />, <br />, <br />. <br />~ <br />~~ <br />~ <br />~ <br />~ <br /> <br />.. .. <br />7 rhyme of Mine <br />Y ,~ I ~. <br />8. Courtt .:;'.*~ . ':h <br />,. .~°State''';•' 'y ~"?1. f <br />. <br />SL ~k:rn% <br />~,% ~ ~. <br />A.' •Ear~ .,~: <br />. <br />~ <br />%c 1; 'FF::~ 1~... <br />.. .. <br />~li~ •,:( ,.- .. tp -. - : <br />. <br />: <br />1i'.i.. ..; '-,"S~~,c2 ~.p <br /> <br />• <br />V~ '"~ <br />~; 'rJ <br />11:~'tameaf:ConurtPerson .. _ TelePhoriE,A7~mber 2„1rti.iYmiof}•_,4_,RT• <br /> <br /> <br /> 13. PRODUCTION AND Ff.E:COMPIJS~~iO -~`, '- <br />' * <br />~ <br />~ <br />~ <br />~ <br />:" <br />.. <br />l - <br />Co <br />-~`~~ .. ~ <br />Mining Method Number oT Tons ~ ,'. <br />"fae'p <br />~-'.~ t T ' <br />a:: :~ <br />. <br />r: - <br />~ F. ,: <br />p~r:•r:. r <br />•..r <br />:4,, <br />'a:",: _~.= <br />g <br />. <br />-' <br />th <br />F <br />e' <br />t <br />S <br />6 <br />~ . <br />- <br />~ <br />1- <br /> <br />_:.: <br />. <br />_ .. <br />... <br />- <br />~`~td) ~.- Ib) e <br />' <br />jee <br />to <br />e <br />+;t <br />. <br />:; <br />. ~,:;i91a arsit.; _~l, <br />d?-P,9~ <br />.:;: ~~ <br />+~ <br />. <br />r'±si r> <br />_ <br />_ <br />.'~... ~. ~ .. . <br />., ;?s. <br /> <br />._. <br />Surface \'A:l ....i: l <br />' <br />.y'. <br />5terjts ~:; .": $ <br />x'`~~ ,.ID.i'.~1-'~, .": 1, <br />onG <br />= <br />r ::~'1:,' <br />; ~ ~. r x:11 ,y (rl. lL)• ~~ <br />~• . <br />b ~ <br />. <br />l <br />~'• <br />Anthracite; - . - <br />, <br />..', f <br />L ~. r,i1 G'k~ ) ~ <br />- <br />,.:,.; <br />..• <br />'. <br />.' <br />~ ~ ; <br />. <br />,. <br />,. <br />~ ; i <br />, <br />. <br />,~, i.t <br />..y .,.R <br />Bituminous, or <br />Subbituminbus <br />Underground • <br />: <br />~ - <br />'...: s`r: <br />, ~'„x t~(rS czrlts- ~: ,;,o <br />~ <br />.. <br />; S•.'+.'TrJ`:"(.~. <br />r C~~~-.;,.;•qM[~ . 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S <br />' <br />:~~. ~~•. •a° <br />National Toll Free Number ~ ~ <br />~:' - <br />any other problem rega~,ding3tid recla>rriHjlon~ee.': ..•~' <br />or <br />. <br />. <br />- 76. CERTI F1CA710 <br />N ~ <br />, : +,° ','.Ia' is a <br />'~j'~j-~`:~- <br />°• <br />~ <br />• _ <br />. <br />~ <br />r <br />. <br />(a.f-9 HEAEBV CERTIFY that the statements make 'herein "••h' 1d.);Su]~saibed~nd.5_wor~ to.Me~hiS-`~'~~^Da <br />~ '~ <br />' <br />~ <br />"` ~` ~ ~~~ <br />` <br />' <br />-?''are True; co late, and correct to~the beet of m know <br />m¢ Y <br />' <br />~ <br />~ ~ <br />':•/ _ <br />>•~ <br />79' 'fn:tllk'Preserty,~ <br />•of- <br />."',-*•;•''~+:~ <br />~ <br />r ~"~~° "~ <br />' ' `~'~ <br />and are made in ood faith. - <br />• <br />' ledge ant? beliEf <br />, <br />- . <br />: •~ <br />'•'~ <br />:. r . <br />fb,J_..Name'of ,zportiny person, corporate off ic6t, event or •~ r . .. - ..'~ ~ _ ~~ ~'!,•.t "'~•„I_r f=~. <br />I` <br />director. on' behalf •pf ~ the operator, or the iperator <br />'. <br />. <br />' r.2: ~,' ~.... .::tSEAII p ~~:. ~ Nt~~ ~~~'.4 <br />~ <br />~ <br />' <br />~'• <br />- <br />- ,.n. <br />(print•in ink br:tYP01'_.". _ - . .. .. <br />.. ... •:L:~ _- <br />.,f <br />f (.r-i. <br />" <br />~.:. .: _ <br />' <br />. .~' :~:' 1 <br />~ ' <br />~ <br />~ <br />3i p!iature ~:' ~' 'Date <br />(c) <br />~ <br />~ ' '~ .NOTARY YUBL+C <br />.•%'`'~?~ <br />.Y c'^ %'•,'i <br />` <br />~ <br />" - ~ <br />%b <br />• ~•:: <br />•( <br />- .. ~ -'NY CorilrnisuL'~ExDires: 79 -.r - ..e: f AZn <br />... <br />_ <br />~ <br />• ~' -- <br />Ptb 00 U.S.C. S~cUon 7231 provld ar that any perwn, colpo:au ollicar apenl or orr Krpr, on [.¢•~Kr W te...1 mme o~n ~r o•wrG Yno.+~r~•, <br />• ~ mekn any f>lu sretem~nL rep•ecemallon m cerliliutlon, of krw rvingly leis to rnoke any casrr a•:L repr..en'sJioe d ceniF~•Loq rrf'~ ~~ <br />- in'thn rrc:ion ~ha+l, upon convin ion, be pv n+sh ed by ~ 1me Or not more then $10,Ou0. or by imp: iss\'*aru b: nm mo: artan aN.i yew o~i\JN~~I <br /> <br />126 -' - - ;. . ~ .ti .r.l <br />FO~I:.CS:}l (Fcvn-~ Fo.m 637~1)'pni:ber•lF'90' <br />