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- - = STATE OF COLORADO DIVISION OF MINERALS AND GEOLOGY Depanment of Natural Resources IJ13 Sherman Sf., Room 2t5 Denver. Colorado 80203 Phone: 11011866-3567 FA%: ()031 83 2-8 106 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 Rule 1.04173), technical revisions, as defined in Rule 1.0411361, and permit revisions, as defined in Rule 1.04190). All revisions are to address the requirements of Rule 2.08.4. Three (3) copies of the revision, including maps, must be submitted in order for it to be complete. CIF NATURAL RESOURCES Roy Ramer Wvemor lama 5. Eachhead E><ecuuve Director Michael B. Lon4 ~ivplaa DirKIU/ 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 contents, if necessary. The revision submittal date should be printed in the lower right corner 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 modified during the review process must be distributed 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 Western Regional Coordinating Center (T999 Broadway Blvd., Suite 3320, Denver, CO 80202-5733), and proof of submittal to OSM must be submitted to the Division prior to implementation of the revision. Permit No.: C - ~ 1 - ~ ~ ~ Date: ~ 1 / ~ ~ / 2 ~ Permittee: Z ~ ~ ~ ~ ~ ~ ~ ~ ~ - C_ ~_ ,ta_ ~ ~~^~ C o 1`L~-g!`L~------- ~I/ Street: 2 9 5 1 5 R 0 U T T - ~, g- - FFB S 1996 City: 0 ~ ~ - ~ ~ ~ ~ 1L_ - - - - Ofv(Sfon o(M(nera(6 a Geo/o9 Y State: ~ ~ Zip Code: ~ ~ ~ b_ L - - _ - - Brief Description of Revision: INSTALLATION OF POWERLINES TO EMD VENT SHAFT DEWATERING BOREHOLE. E FIBER OPTICS LINE AT THE FA('ILI7IFS Public Notice Attached: Yes - No ~ (Required for PRs and TRsI Bond Increase: Yes ~ No - Federal X Non-Federal _ Mine Proposed Change in: Disturbed Area (+/-) - - ~ . ~ Acres Permit Area (+/-) - - 0 0 Acres State Land (+/-) - - ___p . ~ Acres Affected Area (+/-) - - ~ . ~ Acres Federal Land (+/-I - - ~ . Q Acres Private Land (+l-) - - ~ • ~ Acres