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~~ ~`~"~'~ +$ DEPARTMENT OF NATURAL RESOURCES <br />y ~, <br />* T ^ o ~ * David H. Getches. Executive Director <br />~~~'"~ * MINED LAND RECLAMATION DID <br />'" 1876 ~ DAVID C. SHELTON, Director <br />Richard D. Lamm <br />Governor APPLICATION FORM FOR A REVISION <br />TO A COAL MINING AND RECLAMATION PERMIT: <br />This form must be completed and submitted with all requests for minor revisions, as <br />defined in Rule 1.04(73), technical revisions as defined in Pule 1.04(36) and permit <br />revisions, as defined in Rule 1.04(90). All revisions are to address the requirements <br />of Rule 2.08.4. <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 <br />being revised. The revision date should be printed in the lower right corner of the <br />revision pages. If necessary, the Table of Contents should"also be revised. <br />Date : ~ D / U ~/ 8 ~ <br />Perini ttee : ~ ~ ~ - ~ .Q ^~ -. ? ~- ~ ^-'' - - ' ~, - . ~~~ <br />.L ~'~~ L _,~ i .,~ b:~~ ~ fit" <br />Street: ~ o.-,~Q~_.~.QS2----- . <br />_ - - - - - - - ~itCL~~,~~~~~~'~~J~~ Ot'JiSli~~9 <br />City: ~~ lZ Q o ~.Q ~-~ `-= ---------- <br />State: ~,~ Zip Code: ~ L ~ 2~ 3 - - - - - <br />Permit No.: C - $ 1 - ~ ~ ~ _ <br />This box to be filled in by the Division: <br />Type of Revision: - - (PR, TR, or MR) <br />Revision Number _ _ (Sequential by Revision Type) <br />Revision Submittal Date -/ / (Date Received by Division) <br />P.evision Completeness Date -/_/ Revision Incompleteness Date / / <br />Revision Adequacy Due Date -/ / Revision Adequacy Date -/ / <br />Revision Decision Due Date / / Fee X0.00 <br />Brief Description of Revision : ~ ~ ,~ /~ .~ ~ ._L_ 12 ~ - .Q .~- - - <br /> '~~ y L ~-~ L ~ v < ~-L~ ~ L L~ <br />Public Notice A ttached -Yes `~ No (Required for PR's and TR's) <br /> <br />Bond Increase: Yes i/ No <br />Proposed Change in: <br />Disturbed Area (+/-) - - 5 •3 Acres Affected Area (+/-) - - - - Acres <br />Permit Area (+/-) - ~•3 Acres Federal Land (+/-) - - - Acres <br />• State Land (+/-) - <br />- - - Acres Private Land (+/-) - - - Acres <br />Lead Reclamation Specialist - - - <br />6185E <br />423 Centennial Building, 1313 Sherman Street Denver, Colorado 80203 Tel. (303) 866-3567 <br />;V <br />., <br />,~.: 4 <br />.~.,,~,~ <br />.~~a..~ <br />