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<br />`~"" ' -' C04L PFODUCTIOIJ AND RECLAFi4TION FtE REPORT I `-~°n e •-' 30.Y _•: ~-r.tti• 3
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<br />';J~'"1"~. ~ ~~'_.• att J,llnnIn nCrn 74 only UU nu! r. n!r 'n Ite T!'• 19. -J Y1r~R'~"'-'~-"~ -
<br />' •~2 Mark '?:".n th~bn. i"sr ~.'zte Perm.t lJumbel ~`t~~i3 _-_____.__-___.--.,4 t/lme lD Number .+
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<br />l ~ 3:, t r„ndtlon n,te 'i5t13~d'5 02.'01.
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<br />Nantc of Qpt~i at of -~ Or)n 3 n„. ,:-. ._ - ._ .. u. IJ;ane Ut i'ermnlr• __ _.. ___ _ __.___. a '
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<br />II/~a i:ulg Addles: -- ~---- ~-~--~---iNalLng Address -------- ~-~
<br />iPu t1vX 785 AT1+: TEI'.RI I'IAI+~NEY ~~
<br />vita d' lji t Clty - _._ _.. _._~; TAtU^ .. , ~t.
<br />(i~I'tvINIOAU ~ CO }!I~l'!k'
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<br />' ~ LOCATION OF MINE-~ --- _--- - -- `''r =n .:1
<br />C7 Name of 7,41nc T Coumy G~-~-- °Eate ~~g ~ ~Q fti Barest 7o,vn ~'
<br />~ ;ucL bSUR ~1INE ~ LAS At'JI1+ns CO ~ -,
<br />Ill. Name o1 Contact Pelson Te~ephone~Number ~~ I12. Indian Rene rV aLOn andior ITf be
<br />I ------------ono ooo-oonn,{ _ '.,.
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<br />-y`~.~_ ,rte;^ a~ T3. PRODUCTION AND FEE COMPUTATION ~;;~;~ ~t~~~_:
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<br />I Number u1 Tons Fee Fer Ton r ~ -;,. ~ " ~ ~ •' t~"'
<br />~ Coal I lrlimng 15ethnd Sub~eet to the Fee ~ ~~ ~ ~+ ~•'Yj~
<br />Id) ~ 11;) 1 Standard ~. e~ ~•Doll~ig:~'~~_}: ~,
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<br />Snllacc 15 30&.91 x35cr,nt6 nl~ cents=5 ...5,15&:
<br />Anlhrao'r I ' ~ .. ~ ~ •-~
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<br />• IBituminous, ur -- .. -: ,•..:• ;'`. :,s,tl
<br />Subbitummnus ~--Under ytcund i 15 cents" ...or '~~ ~. cxnu=5 ~' ~~"`t~"~'"'~
<br />IUgnite ~ ~ x ]O~conu or ~ ~ 'i'%cents=5 - '>~i •"~ a,`''_
<br />Yti ~ i. .. is :!`...
<br />Total Fee To Re Paid No Later Than Thirty (301 Days Atter The End ~ ' `l . ~ ''-
<br />IOt The Calendar Ouaner - ~ ~ I"'
<br />' 14. Corrections or Additions (Identify by hem Numberr 15. ~OSM~Use Qril ~-r ~ ~ ~ ~ rs: ~~ •
<br />Anach Sheet i} tJore SPace is tJeeded 1. -- '__ ~ ~ ~ ~ ~• •o- _ " ~ .~~'
<br />D.T. No.:~ ~ `'. att ~'',: ~`~ i ~S
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<br />Acilunn~ `•Transaaion No: ~ Account: ;`.Rt;}e.
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<br />I ~~ ,.-•IPzrtlal Pey FOB/Ccsh ~RC~73O!•!'~ r'i
<br />1PLEASE WR17E 'NINE ID 05030b5 02 v' C3ov'tCode -; ~.~~ ~:
<br />UN YOUR CHECK ~ACeipt'Code~ ~• •. j,. `=:.-'
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<br />~ -_-_=----- 251-93C'2
<br />National Toll Free Number Call the toll free number 18001 - ii you ktave any problerTi svi~tFl th~>;#o
<br />i or any other problem regarding the 1=.r.•lamafion fem.
<br />~''``~1~=->- ~' 76. CERTIFICATION t=~ ~' ~``;_. ;"'
<br />((a.) I HEREBY CERTIFY that the statements make herein ~ (d.).Su6+scrilrtd and Ssvom to We this ~' ~ ~>)ay r.;li'`~~
<br />! are True, complete, and correct to the best of my know ~rzv ~7g~`~' {o.the presence of :=~; ~-• ~'F"`
<br />I ledge znd belief, and ale made in nood faith. ~ ., ~ , - ' ~~~!` •`
<br />_ __ ____ _ ; .. tt..~
<br />Ilb.) Name of rePoning arson, corporote officer, agent of ~ ~ ~ ,_ ,''tea `'~
<br />director, on behatt of thr operator, or the operator '• ISEAL ~:~. "t '
<br />(P'ml mink Or tYF~) ~, (y~ ,~. ~.,
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<br />N,a Bartlett ~'"^~ ~,~s.~~•v~ ~, ~I
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<br />Ilc.l Slonature _ 1 Dat N:JTARI'~PURLIC IQ~'a3 ~~~~/`_
<br />I _ ~~2-~ ~ ~,~~,___ ___ ~ ~Y~ _____ _ _._ IJiy Corn misslnn Expues_tg ~~ _ _ -
<br />+ Tnh 30 5 C `Tnron 1737 p: o.~rtles Iha+ „ny person, coipw ert n!LCnr. a~em v. dnret ur on LPI X11 GI : cozl rt~n:z o/•'r ar o' r'~: '.~rn~+~i fY
<br />} r.atee anl' IaISF s:a r.:nm:, reoresc nleliOn 6i ctrulic2\~on, ui t n0•+':ngly Idils to r.~F.E arty t; aren.orr., reM eemal: pr, u• re':d4%'r^n •PJ_.'rtt1
<br />' n tins ern gun stall. voon co... rct~un b- pu ni)he~ by r 1mt of np' nre~e tr.a'. SI O.q Up, ur oY ~mN::onur^m 1oi ^:,+ ~ ^:C L~On P:.t 1 rar o~ Lplh
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