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,-cok <br /> 4, <br /> ` DEPARTMENT OF NATURAL RESOURCES <br /> (� * David H.Getches Executive Director <br /> * MINED LAND RECLAMATION DIVISION <br /> �` 1876 876 DAVID C.SHELTON, Director <br /> tichard D.Lamm <br /> Govemor 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: 0 3 / L Ll __ _ <br /> Perini ttee: �V1 v _ C 0 A) T N <br /> c'o <br /> Street: � Q — BQ <br /> City: N - - - - - - - - - <br /> State: C Q Zip Code: <br /> Permit No. : C - - 0 ) 490 <br /> box to be filled in b the Division: <br /> This Y �j <br /> Type of Revision: M P- (PR, TR, or(� <br /> Revision Number / 5 (Sequential by Revision Type) <br /> Revision Submittal Date 3 1;29181 (Date Received by Division) <br /> Revision Completeness Date �/�/�`l Revision Incompleteness Date <br /> Revision Adequacy Due Date —/ /_ Revision Adequacy Date <br /> Revision Decision Due Date //5/$9 Fee $0.00 <br /> Brief Description of Revision: L Y L ,A/ T L V S lDAJ <br /> ti S.r 1� P <br /> Public Notice Attached - Yes No X (Required for PR's and TR's) <br /> Bond Increase: Yes No Y/ <br /> Proposed Change in: <br /> Disturbed Area (+/-) _ _ d_. 0 Acres Affected Area W-) — — 0 . D Acres <br /> Permit Area W-) _ _0 . C) Acres Federal Land (+/-) — — — Acres <br /> State Land (+/-) 0 Acres Private Land (+/-) — — _ Acres <br /> - :,d Reclamation Specialist T C S 6185F <br /> 423 Centennial Building, 1313 Sherman Street Denver, Colorado 80203 Tel.(303) 866-3567 <br />