REV00564

• Permit No: C1992080
• IBM Index Class Name: Revision
• Doc Date: 7/16/1996
• Doc Name: APPLICATION FORM FOR A REVISION TO A COAL MINING & RECLAMATION PERMIT
• Type & Sequence: TR4
• Media Type: D
• Archive: No

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STATE
DIVISION OF MINERALS AND GEOLOGY
nepartment °r Natural Resornas
llt]She.man St~. Ra°m 71S
De C I ad ae203
JUL 16 1986
Pho~: 1307) 666.3567
`"~' ° °r ° Division a Ininetais s t;eobcly
fAX: (303163]-8f06 APPLICATION FORM FOR A REVISION
TO A COAL MINING AND RECLAMATIDN PERMIT
This form must be completed and submitted with all requests for minor revisions, as defined in Ray Rana,
Rule f .04(731, technical revisions, as defined in Rule f ,0411981, and permit revisions, as defined QOM""°`
in Rule 1.041801. All revisions era to address the requirsmente of Rule 2.08.4, Thrae 13i oopiea ixa m o ream
of the revision, including maps, must ba submitted in order tar it to be template. Michael a. Lag
9ivdlon Ditecmr
All revisions ere to be formatted so they can be inserted into the permit to replace the revised
sections, maps, tables and/or figures. with a rtaviesd table tf contents, if nttoassary. The revision submittal
date ahculd bs primed in the lower right corner of each revision page. A cover letter to the revision should
explain the nature of the ravisitn and reference the specific parmFt sections being revised. .
For federal mines, a copy of the revision application must he submitted to all agendas on the federal meifing
list at the same time the appllcetlon is submitted to the Division, end proof of tlistribution must be submitted
to the Division slang with the application. Capiea of revlsien pages modified during the review proessa must
be distributed in the same manner, along with proof of distribution. Proof of diatribtrtion must be submitted
prior to implementation of fife revision- For non-federal minas, a copy of the application for which the
Division has issued a proposed approval deWsfon must be submitted tc the i]SM Western Regional
Coord'msting Center (1998 Broadway 91vd., Sutte 3320, Denver. CQ 80202-5733], end proof of wfxnittel
to OSM must be submitted to tfre Division prior to imdemematfon or the revision.
Permit No.: C - ~ Z -1Z $..Cd. Date: O ~ ! 1 ~ 13 ~

Street: ~ ~ g _ ~, A ~L ~ F l2 - ~ 2. - -
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city: ~ IL ? Adc ~ Q- -----------
Stata: ~ ~ Zip Coda: ,$ L ~ S2 L - - - - r
brief Descriptlon of Revision: 1 K ~ L ~ ~ ~ ~~ ~ - 3 Q ~

Public Notice Attached: Yes ,c No - (Required for PAs and TRsJ
Bond Increase: Yas - No~ Federal ,_ Nonfederal ~ Mina
Proposed Change ht:
Disturbed Arras i+~ - -Q . ~ Acres
Permit Area (+~ ~ ,~ . „L Acres
State Land 1 t/-) - - Q . n Acres
Af fatted Area 1 t Q V„ - ~ . ~ Acres
Federal I.snd (+!•) .~ - ~- -Q Acres
private lend (~- ~; ~ . ,L Acres
m:lcoal is harelformal8 @65
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