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STATE OF COLORADO DIVISION OF MINERALS AND GEOLOGY Depanmcnt of Natural Resources 1317 Sherman St., Room 215 ' Denver, Colorado 80203 Phone: (3031 a66-3567 FAx:13o31 eli-aloe APPLICATION FORM FOR A REVISION TO A COAL MINING AND RECLAMATION PERMIT This form must be completed and submitted with all requests for minor revisions, as defined in Re,. Ro,,,e, Rule 1.041731, technical revisions, as defined in Rule 1.04136), and permit revisions, as defined ~~ in Rule 1.04(901. All revisions are to address the requirements of Rule 2.08.4. Three (3) copies lame, s. ~«hhead of the revision, including maps,. must be submitted in order for it to be complete. firectrtlve olrect« MichaN ~B. ton{ Oivnion Director All revisions are to be formatted so they can be inserted into the permit to replace the revised sections, maps, tables and/or figures, with a revised table of cor5tents, if necessary. The revision submittal date should be printed in the lower right comer of each revision page. A cover letter to the revision should explain the nature of the revision and reference the specific permit sections being revised. For federal mines, a copy of the revision application must be submitted to all agencies on the federal mailing list at the same time the application is submitted to the Division, and proof of distribution must be submitted to the Division along with the application. Copies of revision pages mod~ed during the review process must be disVibuted in the same manner, along with proof of distribution. Proof of distribution must be submitted prior to implementation of the revision. For non-federal mines, a copy of the application for which the Division has issued a proposed approval decision must be submitted to the OSM Albuquerque Field Office (AFO), and proof of submittal to AFO must be submitted to the Division prior to implementation of the revision. Permit No.: C -, ~ i - o. T (~ Date: ~ ~ / ~ g / ~ j Permlttee: ~ ~' R . A_7?_P E ,R M I ly I N G ~ I_. t7y~ C - ~ \v GQ - - - ~F~,E ~ 1985 Street: ? _o - s o~x - i_ a ~ - - - - - - - PVG 2 009`1 City: c R -A~i-.G - - - - - - - - - - ~`v.\.S~oac\~~~e\a~s~VG State: ~ . ~, Zip Code: s 1_5 2 5 - _ - - - Brief Description of Revision: g E_[.>_t, ~ ~ g_ ~r~ ~ -o_F - - - A P I T L A D D $,_J, ~ D ~-- Public Notice Attached: Yes x Na Bond Increase: Yes _ No x - (Required for PRs and TRsI Federal x Non-Federal - Mine Proposed Change in: Disturbed Area (+/-) _ - - -Acres Permit Area (+/-) - - - _ Acres State Land (+/-) - - - _ Acres Affected Area (+/-) _ - - _ Acres Federal Land (+/-) _ - - -Acres Private Land (+/-) _ - - _ Acres m: \co el\ch ere\ fo rm s\8885