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o_f cow <br /> DEPARTMENT OF NATURAL RESOURCES <br /> o * David H.Getches,Executive Director <br /> MINED LAND RECLAMATION DIVISION <br /> �876 DAVIDC.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: <br /> Permittee: �Street: — <br /> City: L_ L .t'�j - � . .L_ � - - - - <br /> State: Zip Code: - — — — — <br /> Permit No. : C - � - <br /> This box to be filled in by the Division: <br /> Type of Revision: M\�,, (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 $0.00 <br /> Brief Description of Revision: �L i= L — A— <br /> — <br /> Public Notice Attached - Yes No 1-1-(Required for PR's and TR's) <br /> Bond Increase: Yes No <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 /> Lead Reclamation Specialist L t\ c—, 6185E <br /> 423 Centennial Building, 1313 Sherman Street Denver, Colorado 80203 Tel. (303) 866-3567 <br />