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I~ <br />~ STATE OF~OLORADO <br />Roy Romer, Govei <br />DEPARTMENT OF NATURAL RESOURCES <br />MINED LAND RECLAMATION DIVISION <br />FRED R. BANTA, olnetor APPLICATION FORM FORA 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 <br />in Rule 1.04(73), technical revisions as defined in Rule 1.04(36) and permit >fevisions, as <br />defined in Rule 1.04(90). All revisions are to address the requirements of Rule 2.08.4. <br />Three copies of your revision including maps 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 <br />revised sections, maps, tables and/or figures. Explain in the revision what section is being <br />revised. The revision date should be printed in the 1 -corner of the revision <br />pages. If necessary, the Table of Contents should also be revise When the final version <br />of the revision is approved, 7 copies must be sent to M in Denver for Federal mines and for <br />non-Federal mines 1 copy must be sent to OSM at 625 Silver v~1JIIe,. 5W, Suite 310, <br />Albuquerque, New Mexico 87102. The revision may not proceed unti110SM has been provided <br />copies. Copies should be sent certified mail. ~;`k ,I_Ibt~~l~ <br />Date: - -/ - -/ - - ~ ~, OS/in ~gr.:~?t7wu5 <br />Permittee: --------------- ~pto 5'~5f~ <br />I <br />street: --------------- ~fr'„Irk ~J~pz <br />--------------- <br />c;ty: <br />-------------------- <br />State: _ _ Zip Code: - <br />Pertnit No.: C - - ----- ---- <br />Mine Name: <br />Tm s oox to oe tilled in Dy the D1v1s1on: <br />Type of Revision: _ _ (PR, 7R, or MR) <br />Revision Number: _ _ (Sequential by Revision Type) <br />Rev. Submittal Date _ _/_ _/_ _ (Date Received by Division) <br />Rev. Completeness Date: / / Rev. Incompleteness Date: / / <br />- - - - - - - - - - - - <br />Rev. Adequacy Due Date: _ _/_ _/_ _ Rev. Adequacy Date: _ _/_ _/_ _ <br />Rev. Decision Due Date: / / Lead Reclamation Specialist: <br />rler uescrlptlon of Revision: <br />Public Notice Attached -Yes ~Jo Requlre~ Tor~R's and~R's) - <br />Bond Increase: Yes No - ~eaeral Non-Federal Mine <br />Proposed Change in: <br />Disturbed Area (+/-) Acres Affected Area (+/-) Acres <br />Permit Area (+/_) - - - - Acres Federal Land (+/-) - - - - Acres <br />State Land (+/-) -_ - - - Acres Private Land (+/-) - - - Acres <br />6185F (Rev. 10/88) - - - - - <br />215 Centennial Building, 1313 Sherman Street Denver, Colorado 80203-2273 Tel. (303) 866-3567 <br />