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STATE OF COLORADO DIVISION OF MINERALS AND GEOLOGY RECEIVED Deµrrtmenr of Natural Rewurces I Jl l Sherman 51., Room 215 r~ ,If1~f~ l+d~~~~ Denver, Colorado 80203 Q~l. O ~ ~ II Phone: 13071 8663567 FA%:1307183: 1;106 APPLICATION FORM FOR A REVISION TO A COAL MINING AND RECLAMATION PE M T i'~3ATURAL ~vls'on pl MmeraVS & Gdo RESOURCES This form must be completed and submitted with all requests for minor revisions, as defined in RovRo„K, Rule 1.041731, technical revisions, as defined in Rule 1.04(1361, and permit revisions, as defined c°'nef"°` in Rule 1.04(901. All revisions are to address the requirements of Rula 2.08.4. Three 131 copies ERttuhve D~heclrn of the revision, including maps, must be submitted in order for it to be complete. MithdCl B. IOn~ DivRiOn DileCIW 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 (1999 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. Permil No.: ~ - $ 1 - Q ~. $ Date: 1 ~ /Q Z/ 4 Sx Permittee: H4 YiZ E _BE E4IIBCEE_LIMZTEJ2____ L 4 Yi I E _)y 4 ~ _ 1 _ M I H E _ _ _ _ _ _ _ _ _ _ _ Street: P..4~_HQX_14B.fl_______________ City: P B 4 H 18 - - - - - - - - - - - - - - - - - - - - - - State: ~Q ZipCode:$14~$- ______________ Brief Description of Revision:B E y Z E E_ I~ E)y T I E I~ 8 T 1 4)y 4 E_ L H T E B E ;i T ;i ___ R E l4 ___ M I H E_ 4 P E B B T 4 B ~& H E B P 8_ Public Notice Attached: Yes _ xo XX (Required Ior P/ls aid TRs Bond Increase: Yes _ xo ~ Federal XX Non-Federal _ Mine Proposed Change in: Disturbed Area (+/-j - - Q,Q Acres Affected Area (+/-) _ _ Q,g. Acres Permit Area (+/-) _ _ Q.Q Acres Federal land (+/-) _ _ Q,Q Acres Slate Idnd (+/-) _ _ Q,Q Acres Private land (+/-) _ _ Q,9. Acres