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• • iii ~iiii-iiiiii~ iii STATE OF COLORADO DIVISION OF MINERALS AND GEOLOGY rfClicl v r_v DCI6trlmenl n(N.tlural It('HrUIQ't I JI J Shemun 51.. RrKnn d 15 OCT 2 3 1996 Denver, Colorado H02111 I'Intrte: 1 JIIJI I1WrJ 5h7 FAx: I.JOJI IIJx~rllllt. APPLICATION FORM FORA R ~dr'J~ll~ Minerals ~ iiea~o9r TO A COAL MINING AND RECLAMATION PERMIT This form must be completed and submitted with all requests for minor revisions, as defined in Rule 1.04(73), technical revisions, as defined in Rule 1.041136), and permit revisions, as defined in Rule 1.04(90). All revisions are to address the requirements of Rule 2.08.4. Three 131 copies of the revision, including maps, must be submitted in order for it to be complete. I~~~~ DEPAItTMEf~IT OI' NATURAL RESOURCES Nuy Ralrer I,VN.Y 11111 Lvu+ 5 l1w hhrad 1 .11111w,~ u1,1. 1.11 .~,. 11.1r~ n 11,11E i 1~, 1.1,1111,1,•, r1.1 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 tftc revision should explain the nature of the revision and reference [lie 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 (or which the Division has issued a proposed approval decision must be submitted to the OSM Western Regional Coordinating Center (1999 Broadway Blvd., Suite 3320, Denver, CO 80202-57331, and proof of submittal to OSM must be submitted to the Division prior to implementation of the revision. Permit No.: E - $ 4 - Q ~ ~ Dale: 1 4 /2. L 2 ~ Permitlee: ~IEIS_ EI>3 BNE ZBL~_IHE~ _______ Q 4 B L_ B I 1? S E_ M 4 ~_ 1_ M I 1 3 E______ SLreeL ZZS~$_ E4M E8& ,~_IIBIYE__ ________ & II I T E _ 1 4 1 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ city: ~Ban~ _Iau 13CT r413______ ________ Slale: LQ ZipCode:$l ~Q.~- _ _________ ____ Brie( Description of Revision: BE M 4 Y E_ L B E Y_ L 4 812 4 u T_ E $ 4 M _ E E B M I T _ _ _ _ _ _ _ _ _ _ Public Notice Attached: Yes - Xx - - - xo _ - - - - - - - - - - - - - - - - - (Requi~edlo~ PR's and TRs Bond Increase: Yes _ xo XX Fede ral _ Non-Federal }l}( Mine Proposed Change in: Disturbed Area (+/-) _ _ Q.Q Acres Affected Area (+/-) _ _ Q.Q Acres Permit Area (/-) _ _ 4.4 Acres Federal Land (+/-) _ _ Q.Q Acres Stale Land (+/-) _ _ Q.Q Acres Private land (+/-) _ _ Q.Q Acres