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r III IIIilllllllillll' . 999 _ STATE OF CULURADU MINED LAND RECLAMATION DIVISION of ~a~ Department of Natural Resources ,~~~ ~ 4s ~° %18 t3 t3 Sherman St., Roam 215 `~ Denver. CO 60203 '^,~~~~~ 303 866-3567 'ig ~6' Fn x: 303 832-8106 Ray homer. Governor Fred R. Banta, APPLICATION FORM FOR A REVISION Orvision Ortenor TO A COAL MINING AND RECLAMATION PERM I7 This form must be completed and submitted with all requests for minor revisions, as defined in Ru]e 1.04(73), technical revisions as defined in Rule 1.04(36) and permit revisions, as defined in Rule 1.04(90). All revisions are to address the requirements of Ru]e 2.08.4. Three (3) copies of your revision including maps must be submitted in order for it to be complete. A11 revisions are to be formatted so they can be inserted into the permit to replace the revised sections, maps, tables and/or figures. Explain in the revision what section is being revised, The revision date should be printed in the lower right corner of Lhe revision pages. If necessary, the Table of Contents should also be revised. When the final version of the revision is approved, 7 copies must be sent to OSM in Denver for Federal mines and for non-Federal mines 1 copy m~sL be sent to OSM at 625 Silver Avenue, SW, Suite 310, Albuquerque, New Mexico 87102. The revision may not proceed until OSM has been provided copies. Copies should be sent certified mail. Permit No.: C -~ C~ - O Q 3 Date: 1 _/ _ _/ _ _ Permittee: ~~~Y~ ,~1~-~~~ I -- Street: ~~- v~-,~~1----- City: s~~ ~6 ~~------ ---- State: ~ ~ Zip Code: ~ ( y ;L Y - Q ~ ~ ~ MineName: ~i Q~n~-~~~(~--- __-_--- Brief Description of Revision: ~ ~ + p U ~j~, ~- t ~ - ~ Q ~ Public Notice Attached -Yes No (Required for PR's and TR's~ Bond Increase: Yes No Proposed Change in: Disturbed Area (+/-) Acres Permit Area (+/-) - - - -Acres State Land (+/-) _, _. _. Acres Federal Non-Federal Mine Affected Area (+/=) _ _ _ Acres Federal Land (+/-) - Acres Private Land (+/-) Acres 6785E (10/90)