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APPLICATION FORM FOR A REVISION <br />TO A COAL MINING AND RECLAMATION PERMIT Division of Reclamation, <br />Mining & Safety <br />This form must be completed and submitted with all requests for minor revisions, as defined in Rule 1.04(73), <br />technical revisions, as defined in Rule 1.04(136), and permit revisions, as defined in Rule 1.04(90). All revisions <br />are to address the requirements of Rule 2.08.4. Three (3) copies of the revision, including maps, must be <br />submitted in order for it to be complete. <br />All revisions are to be formatted so they can be inserted into the permit to replace the revised sections, maps, <br />tables and /or figures, with a revised table of contents, if necessary. The revision submittal date should be printed <br />in the lower right corner of each revision page. A cover letter to the revision should explain the nature of the <br />revision and reference the specific permit sections being revised. <br />For federal mines, a copy of the revision application must be submitted to all agencies on the federal mailing list <br />(except OSM) at the same time the application is submitted to the Division, and proof of distribution must be <br />submitted to the Division along with the application. Copies of revision pages modified during the review process <br />must be distributed in the same manner, along with proof of distribution. Proof of distribution must be submitted <br />prior to implementation of the revision. <br />Permit No.: <br />Permittee: <br />Street: <br />City: <br />State: <br />COLORADO DIVISION OF MINERALS AND GEOLOGY <br />1313 Sherman Street, Room 215, Denver, Colorado 80203, (303) 866 -3567 <br />RECEIVED <br />C - 1981 - 022 <br />Oxbow Mining, LLC. <br />Elk Creek Mine <br />3737 State Highway 133 <br />P.O. Box 535 <br />Somerset <br />Co. Zip Code: 81434 <br />Brief Description of Revision: <br />Public Notice Attached: Yes No ✓ . (Required for PRs and TRs) <br />Bond Increase: Yes No ✓ Federal ✓ Non - Federal Mine <br />Proposed Change in: <br />Permit Area - <br />Disturbed ( + / -) _ _ 0 • _ Acres <br />Permit ( + / -) _ _ o . _ Acres <br />Affected ( + / -) _ _ 0 _Acres <br />Mineral Ownership - <br />Mineral Private ( + / -) _ _ 0 _Acres <br />Mineral Federal ( + / -) _ — ° _ Acres <br />MR - 101 - Methane Electrical Facility Info. <br />NOV 13 2012 <br />Date: Nov / 8 / 2012 <br />Surface Ownership - <br />Private Land ( +/ -) _ _ o . _ Acres <br />Federal Land ( + / -) _ _ o . _ Acres <br />State Land ( +/ -) <br />0 . Acres <br />Mineral State ( + / -) _ _ . _ Acres <br />