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4; . <br />p4 COQ III IIIIIIIII IIII III <br />~'~$ COLORA~ D\YVISION OF MINERALS ~ GEOLO <br />~•~• 1313 Sherman Stre ,Room 215, Denver, Colorado 80203, (303) 866-3567 sss <br />~ ~H96 • <br />APPLICATION FORM FOR A REVISION <br />TO A COAL MINING AND RECLAMATION PERMIT <br />This form must be completed and submitted with all requests for minor revisions, as defined in Rule 1.04173), <br />technical revisions, as defined in Rule 1.04(136), and permit revisions, as defined in Rule 1.041901• All <br />revisions are to address the requirements of Rule 2.08.4. Three 131 copies of the revision, including maps, <br />must be submitted in order for it to be complete. <br />All revisions are to be formatted so they can be inserted into the permit to replace the revised sections, maps, <br />tables and/or figures, with a revised table of contents, if necessary. The revision submittal date should be <br />printed in the lower right corner of each revision page. A cover letter to the revision should explain the nature <br />of the revision and reference the specific permit sections being revised. <br />For federal mines, a copy of the revision application must be submitted to all agencies on the federal mailing <br />list (except OSMI at the same time the application is submitted to the Division, and proof of distribution must <br />be submitted to the Division along with the application. Copies of revision pages modified during the review <br />process must be distributed in the same manner, along with proof of distribution. Proof of distribution must <br />be submitted prior to implementation of the revision. <br />Permit No.: C - ~ - 0 2 Z Date: ~i / ~ / <br />/ r <br />Permittee: Oti ~o~~ Ca~~„_, 1~~NCr z~ ~ l ~ ~, <br />Street: r, D~ i~J ox .~~ S~ <br />City: ~. 61YI .o J-sSe-f" <br />State: ~ Zip Code: ~~~ / ~ ~ ~/ - <br />Brief Description of Revision: row e r ~; ,,, ~ ~ ~,~ ~ a ~ ,' ~, , <br />Public Notice Attached: Yes _ No r/ (Required for PRs and TRsI <br />Bond Increase: Yes No ~ Federal /Non-Federal Mine <br />Proposed Change in: <br />Disturbed Area (+/-) _ _ ~ . ~ Acres <br />Permit Area <br />State Land <br />(+/-) _ _ ~ . ~ Acres <br />1+/-) _ _ ~. Acres <br />Affected Area (+/-) _ _ (~ . Q Acres <br />Federal Land 1+/-) f~• ~ Acres <br />Private Land (+/-) _ Q . L~Acres <br />