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<br />fWproved by c,4o _ U.S. DEPARTMENT OF THE.INTERIQfi 1. ~ '16rfliatQuert4t~JFr ding`+;l' ^'
<br />&190462(n06951 Office of Surface Mining ~ '~~ E1.March~31~ .1';{ ~~ ,ttii~~
<br />Expires: 52-0791 COAL PRODUCTION AND RECLAMATION, FEE REPORT; [7SePtember 34l ~'1Qeca~ei
<br />19 E ti
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<br />READ INSTRUCTIONS 81=FORE- COMPLETING THIS FbRIJI
<br />I I Ittellrinted intormatwn i~. incorrect or missing mako col rections nr
<br />additions in i[ern 14 only. Do nut write in items 3-I1.
<br />2. Mark "X" in the boz 3a. Sure Permit Number 79.53 ~4. Min2 ID ~ i~. ~l; I' f'+'a
<br />it first re xirt I ~ I "~~ I' r "'~,;;~
<br />I i. _ 3b. PYpuatiun Date , ~l":p, ;~
<br />S tl 3gpl°~. • 9
<br />I';. Naow u1 OPcratoi u5039~5 I6. Nome of ('ermit[nC l.fi•~. ~I, '.-.11 '..-
<br />~.1^'. . t
<br />iTHIN_I<rA0 f'+ASIry r-.Tf:I>+G Itli: !
<br />'e~ ~ :j.q' ., ~:;
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<br />Mailin A.ddr ess _.`....- _._,...__7-._._.__..__. _. ._ .. _ .. _ Mailin 'Address-,: ____.: ,,_._--...._.,._ ,y ; ~( .,'..
<br />PI v BUX 785 ATTN TE.PtR MANUNEY ''~i' ','~r~~;•' '"r.
<br />F'~~NIUAU ~Fta~n CI) __721{:~,~~•~ (,Ity f5ttita.
<br />_.~,.... ,;fir,.
<br />I~ LOCATION OF MINE ~~(~',~ ,:, :;~,• ~,~1,,
<br />17Tme t,f Mine ---.._~.---- --- -- ft. County ~~f--'T ,fate ~'~~ 1 : Nearest' .Qwn' :~ ~'
<br />'UGL hGCIA VINE - ~-- a --- tt , ~,r=,I',
<br />_ .. 1 LA... AeiI AS Cf! .
<br />'j :.:.' .l' i .: 'IM'"I".: ,, ... ...: .~ ..
<br />,-~---
<br />11, Name of Contact Person Telephone~Number ~ i 1 : Indigo Relier,Vation and/ut.j - ; ~~';; ;; .
<br />I
<br />_ _.~_
<br />13. PRODUCTION AND FEE COMRUTATION
<br />~ Coal Mining Method Number of Tons F'e0 Prli',.' i•' ~ '~ w~, ,y ,t ~ .f ', ~1,
<br />(al Ib) Sublect to the fee Sta td '! 6 cantf, td,/~ 11+.~L,S
<br />a ~' D9
<br />F------ ....._ . - - - - -------~ 'I
<br />SI11Iaru 1J 30~.y1, x35cnn'LS or t,ents'$ .~~~~~. ~1,'~~,
<br />~~Mthraere, ~ ~ "~ ~f
<br />Bituminuus, or FI~ -----......._..._.~-- -t-~-,. ._ ,,
<br />Subbituminous ~ ~ ~ ~---~~":it n,', ;tf~~C+~
<br />I Underground -~--.----' x~l5 ceni5' r '' ,t~eflts`=$ ; ,,. ~. q
<br />I ~ •ra~~ ','i. ''~ ir, ..~FCI
<br />lignite x~lOcants ~ or !'cants=$' ~ a,;,;ti;~,~ I~,;p~
<br />--L------~~--~----~- ' ''~'' `
<br />Total Fee To Re Faid No Later Than Thirty f301 Days Atter 7hr End ~ '. ' `"~~' ~ ~l' ~~
<br />Of The Calendar Quarter -- ----.--•=- --~- $ ~~'Or t.+, ..•
<br />14. Corrections or Additions (Identify by Item Number, 1~. OSIN'Use Qtlly. ' ~~_~ ~~" ~ '~' ~~~ ~ '`' ~ . i -,'"'
<br />Attach Sheet if More Space is Neededl. !~ ', ~ I`. "S"
<br />D:T, No: ''" ate I •: ".; . +„).
<br />Action ~~F ~ Transaction`Nd: i /at.Ce{tAltt't '1»
<br />~ PertlgrY,aV ."~~ fa'~'1Cesn 'df~ I
<br />..,,,:
<br />PLEASE WRITE 'MINE ID 0503065 02 v' _ gov't.Catle '' 'r~,...f..jpt`~'1~.
<br />UN'YOUR CMECR - aceiorCbd '' L,t.~''":
<br />' - - -- -------- - ~--1--- --------- ---- .~t' :~.i:.a--
<br />Call t11e toll free number (80012Si-g3f'~Z if yoµ klaye any problem wi~ii~t~'~.fOritl
<br />National Toll Free Number or any other problem rt;garding the teclarnatlon,fine. '
<br />16. CERTIFICATION . ,
<br />I HEREBY CERTIFY that the statements make herein (d.l~ul
<br />are true, complete, and con~act to the best of my know a,
<br />ledge and belief, and are made in good faith. _
<br />Name of reporting person, corporate officer, agent u1
<br />director, on behalf of the operator, or [he operator
<br />(print m ink or type)
<br />Mary Bartlett
<br />T,ne 90 .S. C. Secuon 1432 provides tear any person, carpel are officer, agent or
<br />makes any false sta cement, represenunion or certi4ication, ur knnwrngly rails to n
<br />,n ,Iris Section shall, upon cnnvictiun, he pu nisherJ by a tine o1 nn1 more than $10.0
<br />Iseribed tl Sworn to Me this • - 'G!
<br />~~, 19 ~, in~the presence of .~ , '~"`!, i',
<br />,,~. .,:
<br />' ~ ,1~,"Iti~ "r
<br />)SEA L~ ' . ""n~: "J,~ '1
<br />t7U ~ .i4!-, ..
<br />~ NOTARY PUBLIC 1. ~.~~ y ,:;.
<br />•Ir,;
<br />My Commisslpn Expires: 19 CCC ~ ', 1
<br />__ ;
<br />or, on b I* p1 • Coal mma operalp~' h0 ~ y'r '
<br />V stm erswrtt, repreet:matwn or nerlililpatipnx
<br />by imnnsdnrr+ent fur our more than prra year~pF' ~ h. '
<br />FOHV1 OSl,n ! fRavls:n Frnm 637-1'1~Oalubn., t~Ao' ^. ~I
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