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III IIIIIIIII\IIII III COLORADO DIVISION OF 1~IINERAL~AND GEOLOGY <br />~'.~e~• 1313 Sherman Street, Room 215, Deaver, Colorado 80203, (303) 866-3567 <br />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 defined in Rule <br />1.04173), technical revisions, as defined in Rule 1.041136), and permit revisions, as defined in Rule 1.041901. <br />All revisions are to address the requirements of Rule 2.08.4. Three 131 copies of the revision, including <br />maps, must be 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, <br />maps, tables and/or figures, with a revised table of contents, if necessary. The revision submittal date <br />should be printed in the lower right corner of each revision page. A cover letter to the revision should explain <br />the nature of the 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 <br />list (except OSMI at the same time the application is submitted to the Division, and proof of distribution must <br />be submitted to the Division along with the application. Copies of revision pages modified during the review <br />process must be distributed in the same manner, along with proof of distribution. Proof of distribution must <br />be submitted prior to implementation of the revision. <br />Permit No.: C - $d - O ~ ~ Date: ( / ~ } / ~ ~ <br />Permittee: <br />Street: o~ l$~ -1~c~~ Ccn.iv.-F" ~(.,a~ ~a r <br />~~~~ <br />City: ~)a -I'~ CS e.e,1C <br />State: ~~ Zip Code: $~ ~ ~ ~ - <br />Brief Description of Revision: ~ ~~ ~~~ ~ t ~ •a~^%t Lfb s s -U Q-. <br />l~ ~c r . ~.n ~1~c~S~' I ~ <br />Public Notice Attached: Yes _ No ~Requi~ed for PRs and TRsI <br />Bond Increase: Yes No _ Federal fn-Federal _ Mine <br />Proposed Change in: <br />Disturbed Area Q/-) _ _ ~ . Sgcres <br />Permit Area (+/-1 Acres <br />State Land 1+/-) <br />Affected Area Q/-) _ _ a . ~ Acres <br />Federal Land (+/-) _ _ _ _ Acres <br />Acres Private Land (+/-) _ _ _ _ Acres <br />m: \co al\s h a re\f o rms\8865 <br />