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111IIIII!llllllllll STATE OF DIVISION Of MINERALS AND GEOLOGY Oepanmem of Natural Resources , IJ17 Sherman Sr.. Room 215 Denver. Colorado 80203 Phnne: ~)D31866.7567 +,~Gr.Gn~FD MAR 2 9 1996 F.~x:uo71a3z-aloe APPLICATION FORM FOR A REVISION TO A COAL MINING AND RECLAMATI~~~Q(1IlliTierale & Geology This form must be completed and submitted with all requests for minor revisions, as defined in Rw ROmer Rule 1.04173), technical revisions, as defined in Rule 1.041136), and permit revisions, as defined ~O°`r°Of in Rule 1.04(90). All revisions are to address the requirements of Rule 2.08.4. Three 13) copies lames s. LOChhead Esecmrve Direaa of the revision, including maps, must be submitted in order for it to he complete. Michael B. LOnG Divmm~ Direaur All revisions are to be formatted so they can be inserted into the permit to replace the revised sections, maps, tables and/or figures, with a revised table of contents, if necessary. The revision submittal date should be printed in the lower right corner of each revision page. A cover letter to the revision should explain the nature of the revision and reference the specific permit sections being revised. For federal mines, a copy of the revision application must be submitted to all agencies on the federal mailing list at the same time the application is submitted to the Division, and proof of distribution must be submitted to the Division along with the application. Copies of revision pages modified during the review process must be distributed in the same manner, along with proof of distribution. Proof of distribution must be submitted prior to implementation of the revision. For non-federal mines, a copy of the application for which the Division has issued a proposed approval decision must be submitted to the OSM Western Regional Coordinating Center 11999 Broadway Blvd., Suite 3320, Denver, CO 80202-5733), and proof of submittal to OSM must be submitted to the Division prior to implementation of the revision. Permit No.: C - ~ Z - ~ ~ ~ Date: -Q i /~ s / ~ ~ Permittee: Z ~ .1` ~ Z ~ lL ~ I.~ ~ - ~_ p ,y_ ~ Street: 2 9 5 1 5 - R O U T T - ~ ,~ - ir 2 7 OF City: ~ A I~ - ~ ~ ~ ~ IL. - - - - - - State: ~ ~ Zip Code: ~ ~ ~ IL Z - - - - - Brief Description of Revision: CLARIFICATION OF POND E DESIrN Public Notice Attached: Yes ~ No - /Required for PRs and TRsI Bond Increase: Yes - No X Federal X Non-Federal - Mine Proposed Change in: Disturbed Area (+/-) - - 0 0 Acres Permit Area (+/-) - - 0 0 gcres Affected Area (+/-) _ - ~ ~ Acres Federal Land (+/-) - - 0 0 Acres State Land (+/-) - - 2 , ~ Acres ?rivate Land (+/-) , - 0 0 Acres