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+! <br />_~ <br />+t Of~` 01~~ <br />~" w <br />e 'r, ~ ~ e <br />• hh~ -~--••-- 'i <br />.~~ 6 , <br />M,clu,d O Le,ee <br />Gwerwo• <br />0-~%12.'S~ 11:55 <br /> <br />X05 <br />III III'IIIIII'IIIII <br />DEPARTMENT OF NATURAL RESOURCES <br />GhP H Gel~hen Frew hve Oueclur <br />MINED LAND RECLAMATION DiVIS11~N <br />OeY1~G.5HE LT OH, VHa G[Ot - <br />APPLICATION FORM FOR A REVIS]ON <br />TO A COAL MINING AHD RECLAMATION PERMIT <br />... ,.. <br />This form must be completed and submitted with ail requests fDr minor revilslo~nse Of <br />defined in Rule 1.04(73), technical revisions as defined in Pule 1.04{36~ as-d peraiit' <br />revisions, as defined in Rule l,Cd(90). All revisions are to address the regdle'OIatIM6- <br />of Ru]e Z,OH,4, <br />.. <br />All revisions are to be formatted so they tan be inserted into the permit't0 r~eplad0 ~' <br />revised sections, maps, tables and/or figures. Explain in the revision +1hst sOCt10h'i5 <br />being revised. The revision date should be printed in the lower right COM~Ier of the <br />revision pages. Ii necessary, the Table of Contents should also be revised. ' <br />Date: / i / i. <br />Permittee: i ~ ~, i +, ~, <br />Street: ~ ------i y _----- <br />City: ~ ------------- ._ .... <br />State: ~ ~ Zip Codc: i 1 ~ ~ - _ _ T .~ <br />Permit No.: C - - ~~ 1 u <br />This box to be fi1]ed in by the Di VSsion: <br />Type of Revision: _ _ (PR, TR, or MR) <br />Revision Number - _ (Sequential by Revision Type) <br />xevision Submittal Date _/_/_ (Date keceived by Division) <br />Fevision Comaleteness Date r /~/ Revision Incompleteness Dete J / <br />kevision Adequacy Due Oate _/ /` Revision Adequacy Date ~/ / <br />P.evislon Decision Gue 0zce / / Fee SU.UU <br />Brief Description of Revision: _ ~' n - _ I 1 _ o t. U,,,,pl~~-~'_g <br /> <br />Puhlit I:otice A.itacl~er' - Yes __ _ I:o ;_ iF.eduired for PR's and TR'S) <br />hond ]n;reasc: Yes Np <br />PruNused Cl,anue in: <br />Cistur5ec: Area (+/-) _ _ P.cres Affected Area (+/-) _ _ <br />_ <br />^ AcreB <br />Permit Area (+/_) _ _ Aires Federal Land {+/_) <br />_ _ ACreB <br />~tut~• land (+/-} _ T __. Aires Privzte Land (+/_) ___. _ ` Acres <br />Lead Reclamation Specialist ~ 6185E <br />473 L'entennial t3u~ldmg, Y313 Sherman Street Denver, Colorado 802D3 Tet. (3D3} B9B 3857 <br />