_GENERAL DOCUMENTS - C1981017 (241)

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of.Cow DEPARTMENT OF NATURAL RESOURCES * 1 s o * David H.Getches,Executive Director MINED LAND RECLAMATION DIVISION 1876 DAVIDC.SHELTON, Director Richard D.Lamm Governor APPLICATION FORM FOR A REVISION TO A COAL MINING AND RECLAMATION PERMIT This form must be completed and submitted with all requests for minor revisions, as defined in Rule 1 .04(73), technical revisions as defined in Pule 1 .04(36) and permit revisions, as defined in Rule 1 .04(90). All revisions are to address the requirements of Rule 2.08.4. All revisions are to be formatted so they can be inserted into the permit to replace the revised sections, maps, tables and/or figures. Explain in the revision what section is being revised. The revision date should be printed in the lower right corner of the revision pages. If necessary, the Table of Contents should also be revised. Date: o 5 / :2 3 / Pz ?.a_ Permi ttee: L L Q = C O A) 7—,L AJ — S A/ C — Street: L' 0 X — S C G - - - - - City: �l K rS' 0 /V 0 C �= - - - - - - - - - - State: C C Zip Code: P l _ O_ 3 - — — —Permit No. : C - ? 1 - �i ,� This box to be filled in by the Division: Type of Revision: — — (PR, TR, or MR) Revision Number _ _ (Sequential by Revision Type) Revision Submittal Date _/ / (Date Received by Division) Revision Completeness Date —/ /_ Revision Incompleteness Date Revision Adequacy Due Date —/ / Revision Adequacy Date Revision Decision Due Date / / Fee $0.00 Brief Description of Revision: (J C z— L 1 C-7 1 1 Public Notice Attached - Yes No (Required for PR's and TR's) Bond Increase: Yes No Proposed Change in: Disturbed Area W-) — — / .,I Acres Affected Area W-) — — .— Acres Permit Area W-) — — D . 0 Acres Federal Land W-) — — o Acres State Land W-) — — Q Acres Private Land W-) L Acres Lead Reclamation Specialist L M j 6185F 423 Centennial Building, 1313 Sherman Street Denver, Colorado 80203 Tel. (303) 866-3567