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of c~to <br />'C '~~ ~9 <br />Fe ~ $ DEPARTMENT OF NATURAL RESOURCES <br />y ~ ~ ' y David H. Getchea. Eaacuhve Director <br />MINED LAND RECLAMATION DIVISION <br />X876 ` DAVID C. SXELTON, Dlnetor <br />Richartl D. Lamm <br />Governor APPLICATION FORM FOR A REYISION <br />TO A COAL MINING AND RECLAMATION PERMIT <br />This form must be completed and submitted with all requests for minor revisions, as <br />defined in Rule 1.04(73), technical revisions as defined in Rule 1.04(36) and permit <br />revisions, as defined in Rule 1.04(90). A11 revisions are to address the requirements <br />of Rut a 2.08.4. <br />All revisions are to be formatted so they can be inserted into the permit to replace the <br />revised sections, maps, tables and/or figures. Explain in the revision what section is <br />being revised. The revision date should be printed in the lower right corner of the <br />revision pages. If necessary, the Table of Contents should also be revised. <br />street. LlZd->~-Z€~a2a!-SLR. <br />~~~ ------------ OCR ~;$i~~~ <br />city : G Q ~ r2 Q A-~ Q - ,~ ~ ~ L a.lrc ~ M1NEU rv?~~a 151oN <br />State: ~ O Zip Code: ~ Q gg ~ - - - - ~2ECLHMATTv <br />Permit No.: C - ~ L - Q LZ ~ <br />Date: / Q/~2 Z/ 8 Z <br />Permittee: ~/f LS E~- S 1€ E ~--- <br />This box to be filled ih by the Division: <br />Type of Revision: _ _ (PR, TR, or MR) <br />Revision Number _ _ (Sequential by Revision Type) <br />Revision Submittal Date _/_/ (Date Received by Division) <br />Revision Completeness Date -/ / Revision Incompleteness Date -/-/ <br />Revision Adequacy Due Date -/ / Revision Adequacy Date -/ /- <br />Revision Decision Due Date / / Fee 50.00 <br />Brief Description of Revision: ~~1 1~G~E^~1 ~ F ~v~ ~2 ~ <br /> ~cLtr1- Qc~~~os'rL•/G ---- <br />Public Notice A ttached - Yes _ No (Required for PR's and TR's) <br />Bond Increase: Yes _ No <br />Proposed Change in: <br />Disturbed Area (+/-) _ _ _ _ Acres Affected Area (+/_) _ _ _ _ Acres <br />Permit Area (+/-) _ _ _ _ Acres Federal Land (+/-) <br />_ <br />Acres <br />State Land (+/-) Acres Private Land _ <br />_ <br />(+/-) Acres <br />Lead Reclamation Specialist - - - 6185E <br />423 Centennial Building, 1313 Sherman Street Denver, Colorado 80203 Tel. (303) 866-3567 <br />