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STATE OF COLORADO DIVISION OF MINERALS AND GEOLOGY Depanmenl of Natural Resources I^~ 1313 Sherman Sl., Room 215 Denver, Colorado 80203 Phone: 1303) 866-3567 PAx:13031~32-8106 APPLICATION FORM FOR A REVISION TO A COAL MINING AND RECLAMATION PERMIT DEPAATME[vT OF NATURAL RESOURCES This form must be completed and submitted with all requests for minor revisions, as defined in Roy Romer Rule 1.041731, technical revisions, as defined in Rule 1.04(1361, and permit revisions, as defined cover^ur in Rule 1.04(901. All revisions are to address the requirements of Rule 2.08.4. Three (31 copies lames S. Lochhead of the revision, including maps, must be submitted in order for it to be complete. E%cubVe °1fetor ntichael e. tong Division Director 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 Albuquerque Field Office (AFOI, and proof of submittal to AFO must be submitted to the Division prior to implementation of the revision. Permit No.: C - Date: / / Permittee: _____________~ Street: _______________ - - - - - - - - - - - - - - - City: - - - - - - - - - - - - - - - State: _ _ Zip Code: _ _ _ _ _ - _ Brief Description of Revision: _ _ _ _ _ _ _ _ _ _ _ _ _ _ - - - - - - - - - - - - - - Public Notice Attached: Yes _ No _ (Required for PRs and TRs) Bondlncrease: Yes No Proposed Change in: Disturbed Area (+/-) Permit Area (+/-1 Federal Non-Federal Mine Acres _ Acres State Land (+/-) _ _ _ _ Acres m: \co el\s h anal fo rm s\8865 Affected Area (+/-1 _ _ ~ _ Acres Federal Land (+/-) _ _ _ -Acres Private Land (+/-) _ _ _ _ Acres