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STATE OF COLORADO <br /> MINED LAND RECLAMATION DIVISION oF'coto <br /> Department of Natural Resources <br /> 1313 Sherman St., Room 215 <br /> Denver,CO 80203 * . <br /> 303 866-3567 <br /> FAX 303 832-81 06 �a�s <br /> Roy Romer, <br /> Governor <br /> Fred R.Banta, <br /> APPLICATION FORM FOR A REVISION Division Director <br /> TO A COAL MINING AND RECLAMATION PERMIT <br /> This form must be completed and submitted with all requests for minor <br /> revisions , as defined in Rule 1 .04(73), technical revisions as defined in <br /> Rule 1 .04(36) and permit revisions, as defined in Rule 1 .04(90). All <br /> revisions are to address the requirements of Rule 2.08.4. Three (3) copies of <br /> 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 <br /> replace the revised sections, maps, tables and/or figures. Explain in the <br /> revision what section is being revised. The revision date should be printed <br /> in the lower right corner of the revision pages. If necessary, the Table of <br /> Contents should also be revised. When the final version of the revision is <br /> 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 <br /> 310, Albuquerque, New Mexico 87102. The revision may not proceed until OSM <br /> has been provided copies. Copies should be sent certified mail . <br /> Permit No. : C <br /> Date: <br /> Permittee: <br /> Street: i _ ` L� _3L p EL _ <br /> City: ]a <br /> State: _C Zip Code: _2 k _a Q 2,, - <br /> Mine Name: liK <br /> l <br /> � � � � � _ <br /> Brief Description of evision: -f— a _'�k 3a �� L p <br /> Public Notice Attached - Yes No , (Required for PR's and TR's) <br /> Bond Increase: Yes No Federal 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 (10/90) J <br />