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�w of COZ" <br /> N� 90 DEPARTMENT OF NATURAL RESOURCES <br /> * GF o *; David H.Getches,Executive Director <br /> MINED LAND RECLAMATION DIVISION <br /> 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 Rule 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 /> Permi ttee: /�' l �� — G D �'J_ — <br /> Street: ; D Y� — 5 D ® - - - - - - - - <br /> - — — — — — — — — — — — — — — <br /> City: G14 0 /'J - - - - - - - - - - <br /> State: G' D Zip Code: — <br /> Permi t No. : C - 19� f - D i 7 <br /> This box to be filled in by the Division: <br /> Type of Revision: Q (PR, TR, or MR) <br /> Revision Number ��_� (Sequential by Revision Type) <br /> Revision Submittal Date 7/ / (Date Received by Division) <br /> Revision Completeness Date -7/ 7 /e? Revision Incompleteness Date <br /> Revision Adequacy Due Date —/_/_ Revision Adequacy Date <br /> Revision Decision Due Date % //7/C° Fee $0.00 <br /> Brief Description of Revision: l/ S — A) A 6 � — '7 <br /> 7- 6) e+1 <br /> Public Notice Attached - Yes No ✓ (Required for PR's and TR's) <br /> Bond Increase: Yes No V <br /> Proposed Change in: <br /> Disturbed Area (+/-) _ _D._ Acres Affected Area (+/-) — — 0.— Acres <br /> Permit Area (+/-) _ —_ 0._ Acres Federal Land (+/-) — — 62 Acres <br /> State Land (+/-) 0 Acres Private Land (+/-) — — Acres <br /> Lead Reclamation Specialist J G 6185F <br /> 423 Centennial Building, 1313 Sherman Street Denver, Colorado 80203 Tel. (303) 866-3567 <br />