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STATE OF COLORADO <br />DIVISION OF RECLAMATION, MINING AND SAFETY <br />Department of Natural Resources <br />1313 Sherman St., Room 215 <br />Denver, Colorado 80203 <br />Phone: (303) 866 -3567 <br />FAX: (303) 832 -8106 <br />AVS Annual Review <br />Inspection Worksheet <br />Date 2(,- 111DV 2012 <br />Mine Name/Permit Number qj to I mine -1951 `635 <br />Inspector Signature <br />Based on your ON -SITE Observation, please answer the following: <br />1) Mine ID sign <br />2) <br />3) <br />a) Permittee L CC 90_. 7� <br />b) Operator <br />C) MSHA ID 0-5 <br />Direct inquiry (of persons on the site) <br />a) Permittee G Cc <br />1 <br />b) Operator <br />(not required to be on sign) <br />COLORADO <br />D IV IS I ON OF <br />RECLAMATION <br />MINING <br />SAFETY <br />c) MSHA ID �� -�. KI�� Z4�� Lc�S <br />�✓�'_ G'�'�'� <br />Is ownership /control information for permittee and operator noted in field consistent with <br />what is listed in the permit application? Yes y" No <br />If No, what is in conflict? <br />DRMS is required to verify this information as specified in the AVS MOU if the permitting action was <br />approved subsequently to the MOU (renewal, transfers and revisions). Annually as long as coal <br />extraction from the site has not been completed, DRMS must determine whether officer /controller <br />information is complete and accurate in AVS. In making the determination of complete and accurate <br />information, on -site observations and direct inquiry of persons on the site is necessary. The information <br />on this form will be verified with AML, MSHA, and ETA information in AVS. Please return the form to <br />Mary Rodriguez to be verified in the AVS. <br />Office of Office of <br />Mined Land Reclamation Denver • Grand Junction • Durango Active and Inactive Mines <br />