REV98207

• Permit No: C1980007
• IBM Index Class Name: Revision
• Doc Date: 6/18/2003
• Doc Name: USFWS Request for Depredation/Nest Removal
• From: Mountain Coal Company
• To: USF & Wildllife Service
• Type & Sequence: MR295
• Media Type: D
• Archive: No

°•" Department of the ]nterior Fxp;res oano2ooa
oam No. rota-oozz
~a U.S. Fish & Wildlife Service
®
Federal Fish and Wildlife License/Permit Application Form
Return to: Click here for addresses Type of Activity:
Migratory Bird Pemtlt Office
U.S. Fish and Wildlife Service Migratory Bird -Depredation
P.O. Box 25486 - DFC
Denver, CO 80225-0486
303-236-6171 Michael Garcia
A. Corn lete if a 1 ' as an individual
I.a Last name: 1.6. First name: l.c. Middle nazne or initial: l.d. Suffix
l.e Doug business az (dba): 2.a Street Address (line q: 2.b. Street Address (line 2):
2.c. Street address (line 3): 3.a. City: 3.b. Comty: 3.c. Province: 3.d. State:
3.e. Zip code m postal code: 3.f. Country (only for non-co~emial): 4. Date of birth (mm/dd/yyyy): 5. Social Security No:
6. Occupation: 7. List of any business, agency, organizational, or insRmdonal affiliation associated with the wildlife or plants to be covered by this
license or penrdC
8. Home telephone number. 9. Work telephone number: 10. Fax number. I1, E-mail address:

Complete if applying a
B.
s a
usiness, corporation, public agency or institution
b
w
N~nie o~bu~si~oriip~rty~1°.~.aWes~~k Mine
oun ~n oa I
~
7
Coal MmPng ess as (dba): 2. Tax idwtification no.:

43-1811130
3.a Street address (line 1):
5174 Highway 133 3.b. Street address (line 2):
P.O. Box 591 3.c. Street address (line 3):
4.a City:
Somerset 4,b. County
Gunnison 4.c. State:
CO 4.d. Zip code:
81434
S.a. Principal officer-Last name:
DiClaudio S.b. First name: - ~
Gene S.c. Middle name m initial
E. S.d SufSx
S.e. Principal officer title:
President 6. Describe the type of business; agency, or iastimtion:
Coal Mine ..
7. Home telephone number.
[phone] 8. Work telephone number:
Same 9. Fax number:
[phone] 10. Email address:
[e-mail]

C. All applicants complete
1. Do you cuaently have or have you had any Federal Fish and Wildlife License or Permit?
Yes ~ If yes, list the number of the most recrnt license m permit you hold: No
2. Slave you obtained any required state or foreign government approval to conduct the activity you propose?
Yes ~ If yes, provide a copy ofthe license mpermit No ~ Not Requved
3. Attachments: Complete the additional pages of this application. Application will not be considered cotoplele without these pages. Incomplete applications maybe
returned.
4. Enclose check or money order payable to the U.S. FISH AND WII-DLIFE SI:RVICB in the amount of $25.
Institutions which qualify under 50 CFR 13.11(d)(3) may be exempt from fees.
5. CertiSeatioa: T hereby certify that I have read and am familiar with the regulations contained in Title 50, Part 13, of the Code of Fedeml Regulations and the other
applicable parts in subchapter B of Chapter I of TiOe 50, and I further certify that the information submitted in tlils application fox a license or permit is complete end
accurate to the best of my knowledge and belief. I understand that any false statement herein may subjem me to the crindnal penalties of 18 U.S.C. 1001.
6. Signature (in ink) of applicant or person responsible fm pemdt in Block A m B
{ rr • ~ ta~a.c~" t o 7. Date (mm/dd/yyyy);
06/13/2003
Form 3-200-13 Rev~(GR001 Please contimte oarndpage pagelof 2