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~: °*~ STATE OF COLOCtADO <br />• •~$ Roy Ramer, Governor <br />DEPARTMENT OF NATURAL RESOURCES <br />MINED LAND RECLAMATION DIVISION <br />FRED R. BANTA, Dlnetor <br />APPLICATION FORM FOR A REYISION <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 revisions, as <br />defined in Rule 1.04(90). A11 revisions are to address the requirements of Rule 2.08.4. <br />Three copies of your revision lncluding maps must be submitted in order for it to be complete. <br />All revisions are to be fcrmatted so they can be inserted into *he 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 lower right corner of the revision <br />pages. If necessary, the Table of Contents should also be revised. When the final version <br />of the revision is approved, 7 copies must be sent to OSM in Denver for Federal mines and for <br />non-Federal mines 1 copy must be sent to OSM at 625 Silver Avenue, SW, Suite 310, <br />Albuquerque, New Mexico 87102. The revision mdy not proceed until OSM has been provided <br />copies. Copies should be sent certified mail, <br />Date: ~-/ 11-/ ~y- <br />• Permittee: F„P ~A,o1gJ`pal~rnr,- - - - - - - - <br />Street: F, j ~x-g4~ - - - - <br />- - - - - - - - - - - - - - - <br />City: Florence----------------- <br />State: ~ Zip Code: 81226 - - - - - - <br />Permit No.: C - Fi- - F74_ - '- <br />s ox e i e to y e Dtvts~on: <br />Type of Revision: - - (PR. TR, or MR) <br />Revision Number _ _ (Sequential by Revision Type) <br />Revision Submittal Date _/_ /_ (Date Received by Division) <br />- Revision Completeness Date - /-/ Revision Incompleteness Date -/-/- <br />Revision Adequacy Due Date - /-/ Revision Adequacy Date -/ /- <br />Revision Decision Due Date / / Fee 50.00 <br />Brief Description of Revision: lnsidental ~~•~ - - - <br />Public Notice Attached - Yes ~--Ro -(Requtr~ ~r~R s andfit s)- - - <br />Bond Increase: Yes No g <br />~deral Non-Federal Mine <br />Proposed Change in: _ <br />. <br />Disturbed Area (+/-) Acres Affected Area (+/-) 46 .8 Acres <br /> <br />Permit Area <br />(+/-) - - <br />q~.~ Acres Federal Land <br />(+/-) - - - - Acres <br />State Land (+/-) - - Acres Private Land (+/-) - - - Acres <br />Lead Reclamatio n Special~t ~ 6185E (Rev-2788) <br />423 Centennial Building, 1313 Sherman Street Denver, Colorado 80203-2273 Tel. (303) 866-3567 <br />