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iii iiuiiiiiiiiiiii STATE OF COLORADO OIy1510N OF MINERALS wN0 GEOIOGy txwR,M,rI ar N,i~,m ~, RECEIVE; D uu sn«a++~ s,.. Room:I s arm,. cob,.m ouzo) ~' UCT 05 Pho,rc: UOII e66-)S67 FN(:13071 672.6106 APPLICATION FORM FOR A REVISION To A COAL MBrtlNp AND RECLAMAT101J~RFera~s S Geology This form must be completed and submitted with a9 requests for minor ravisiorl:. as de!lned in R„ p,,,,,, ' ' Rule t .041731, technical revlsior~a, as defined in Rule 1,04(381, and permit revisions, as defined ~^~^~ in Rule 1,04(901. All revisions are to address the requirements of Rule 2.08.4. Three f31 copies a~.., s. rocHRw of the revision, including maps, must be submitted in order far it to lee complete. r"`"`"` o"°"°` Mi[haN @. larq Oi.'ryyr p'vKbr All revisions are to be formatted ao they can be inserted into the permit to replace the revised settions, maps, tables and/or f'Igures, with a revised Ubls of wntents, 'If necessary. The revision submittal date should be printed in the lowei right corner of each revision pope. A Dover 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 ell agtrleies on the federal mailing list at the same time the application is submitted to the Division, and proof of diavibution must be submitted to the Diviaion along with the applirtian. Copies of revision pages muddied during the review process must be distributed in the same manner, along with proof of diatributbn. Proof of distr~tttion must be submitted prior to implementation of the revision. For non-federal mines, a copy of the appGetion for which the Division has issued a proposed approval deciaion must be submitted to the OSM Albuqusrgw Frold Office (AFO), and proof of submittal to AFO must be submitted to the Division prior m implsrtwntation of the revision. Permit No.: c - ~ ( - ~ L 3 Date: _ L / ~ 1 I 1 ? Permittee:. ,~ 1- S ~ .u _ ~ ~ .S d v Q ~ 5 - Sti e street: L /1 3 D o ,.,L~ GL~~1 i~ / Z- - - City: ~CS % (7 /LJ -------- State: ~' ~ Zip Code: ~ ~ D ~ r _ _ _ _ Brief Description of Revision: /~ C AJ ~r-rJ A L_ D Z f P,Q.~a*_'(` - - ---------------- Public Notice Attached: Yes - No .~ (Required for PRs and TRsJ Bond Increase: Yes - No _ Federal K Non-Federal - Mine Proposed Change in: Disturbed Area (+/-)_ - - -Acres Permit Area (+/-) - _ i _ Acres ANected Area (+%-) - - - -Acres Federal Land (+ /-) _ _ - `Acres State Land (+/-) - - - . -Acres m:loodlshn~lrorm ~t8805 Private Land (+/-) _ _ ~ -Acres