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r.pn~o.rtl u, er.o U.S. DEPARTMENT OF THE INTERIOR t. CalenCm Guwta: End.ry ~.
<br />~ a7?CaL?In!l59 011ice o` Surface t/Itning OMa~ch 31 .:uJJnt' 3G
<br />' E•p"`'' =~°'jt COAL PRODUCTION AND RECLAMATION FEE REPORT I uScptemlr-r 30. ~: Gercm"t.u••3'
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<br />7. Name of Mine T County 0 ~ : Stale ~ 10. Nerrest Town •~ ,
<br />iut1, hCUR i1INE I LAE AriIt+n3 CU .'. .'~
<br />IG. Name of i'ematr~ -_~ •~- ~-_- -
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<br />4 Mine ID Number ,, ~r
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<br />ng Address - ,.,
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<br />I LOCATION OF MINE ti .':,
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<br />I;,. Na~~~~ of Opr•ra'.oi O S n 3 () t,
<br />lTnIfr]l,A:1 tsASJrv r1jr.I:~G INC
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<br />IMai:ing Pddr css
<br />IPIi biiX 78.5 AT1N TE~aiiI_tIAi7UNEY
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<br />:.EAU iNSTHUCTIUNS BEFORE COMPLE~fING TI1iS FDRh1
<br />~' •Reprintcrl inf or matiun c ~ncorreet m misinq make er~rre~lruns ri:
<br />ad'Ll~ons in item 74 only Do nut wntr .n items 317.
<br />7 Matk . X" in the bn: ~ s' `Nate Pcrm~l Number 7r)~~i3 ---'- - ------. ~ -
<br />of Contact Pelson
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<br />Telephone Number -~~ ~ ~ 12. Indian Reservation and/or ,Tf be ,`:•. -
<br />noo ^0000{70, '
<br />13. PRODUCTION AND FEECOMR•UTATION s~^-•~~~j
<br />Coal hlining Alethnd I Number of Tons Fee Per;Tnn ,~ ~ ~ `~, ~;,•`n.,.~ ' .F v1
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<br />lal i Ih7 Subject to the f-ee Standard ~: ercentepe ~ ~~Dolla7S.=°~i;_:-~
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<br />15, 308.91 x 35 cnrits : ~o
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<br />Total Fce To Re Paid No Later Than Thirty 1301 Days After The End ~ ~ ~~ •
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<br />~Of The Calendar Duarter "s
<br />-~~ 5 5,~ 358.,
<br />'14. Corrections or Additions Ildantify by Item Number,, 15, ~OSM•Use Qr1! ~ ~- '~ ~r "~ ~~~ ~";:~~~ "~~
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<br />Attach Sheet if More Space is Needed 1,
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<br />ate ~r • ~s., , ,II
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<br />~ Partfal~P.by ~~. FOHICosh REB30ta'~
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<br />IPI.EASE WRITE 'MINE ID 0503065 02. 5' Oov'cCotle ;. .,rti.,
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<br />YOUR CHECK
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<br />you ktave any problem with ttt~$#o
<br />Call the toll free number 18001 if
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<br />' National Toll Free Number
<br />I or any other problem regarding the t-clamafion;iep.. '
<br />_ 16. CERTIFICATION ~ _ ~= ~?s:,:;"':."
<br />la.) I HEREBY CERTIFY that the statements make herein (d I,.Sutiscrilred and Sworn to Me this •DaY Ot"'
<br />! are true, complete, and correct to the best of my know f~6~ ~7g
<br />~~,:p.the ~ ""
<br />Presence o1 .="; '-•'~"(~'.r
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<br />J ledge and beliel, and are made in good faith. _
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<br />Ib.) Name of reporting person, corporate officer, agent of .~ ~
<br />director, on behalf of the operator, or the operator ~ ~.p ISfAL / '~" 4~7•
<br />(print in ink or tYPel
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<br />Mary Bartlett ~~ft, Chli:T^ , CA:.. ;-..
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<br />NUTARY~PUBUC IR
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<br />(clS~iagn~a~,ture y/n~, / ~Dat
<br />/~.C?'2 1 ,- "L2~-CL:~ ~9 ~~~ My Commission Expues 19 ~ '` ~i"I
<br />Lu< 3D l~i.5 C Senion 1737 piov~des Char any person, coypu are on ¢e~, eoenl m do eemr, on bpha^ 01 a coat mu,a oprr at o~ why r,no.•: i~ry
<br />~ mer,e5 any false s[aremen[, repr[sentaliOn or cerlil¢mion, w 4no.v,ngly tails to r-u ka arty stet enwn;, repr remarnn of re•t dca,inn •eqv ftetl'
<br />m rhis sec non shall, voon conrkriun, b¢ pu nnhetl by a fine or no: n•o~e than 510FiD0, ur Uy imnrisonmem Iw ^or mole than .u+a 1'rai o~ LOih
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