Submit two (2) copies.

STATE OF WYOMING
DEPARTMENT OF ENVIRONMENTAL QUALITY
LAND QUALITY DIVISION
APPLICATION
FOR PERMIT TO MINE
OR AMENDMENT TO A PERMIT TO MINE
OR COAL PERMIT RENEWAL

1. (a) Name, telephone number, and mailing address of applicant:
Name:      Telephone:
Street:      Fax:
City: State:       Zip
(b) If the applicant is a   partnership,   association,    corporation, or   limitied liability company
the names and addresses of all managers, partners and executives directly responsible for operations in this State:
Name:
Title:
Phone No.		 Address: Street
City
State Zip
Name:
Title:
Phone No.		 Address: Street
City
State Zip
Name:
Title:
Phone No.		 Address: Street
City
State Zip
Name:
Title:
Phone No.		 Address: Street
City
State Zip
2. Name, address, and telephone number of the agent or person to whom any notice under the provisions of Wyoming Environmental Quality Act or Rules and Regulations adopted thereunder may be sent:
Name:       Telephone:
Street:       Fax:
City:     State:       Zip
3. Attach the following information as part of the specific appendices:
(a) APPENDIX "A"
Names and addresses of surface and mineral owners of record within the proposed permit (amendment) area.
(b)  APPENDIX "B"
(i) Names and last known addresses of the owners of record of the surface rights of the lands immediately adjacent to the proposed permit (amendment) area.
  (ii) Names and last known addresses of any other persons within one-half (1/2) mile having a valid legal estate of record.
 (iii) For surface coal mining operations, the names and last known addresses of coal ownership immediately adjacent to the proposed permit (amendment) area.
NOTE: Appendices "A" and "B" shall each be accompanied by maps showing the ownership locations required by the respective appendices. Mapping of (b)(ii) is not required.
(c) APPENDIX "C"
  (i) All lands to be included in the proposed permit (amendment) area shall be tabulated by legal subdivision, section, township, range, county, and municipal corporation, if any, and the number of acres for each subdivision listed.
   (ii) Lands which are to be part of the proposed permit (amendment) area, for which no right to mine is claimed shall be identified in item (c)(i) above as such and tabulated separately listing the number of acres for each legal subdivision.
 (iii) Lands which are located within other permit areas shall be identified and a copy of the land use agreement with the other permittee shall be attached as part of this application.
 (iv) An original United State Geological Survey topographic map, clearly outlining and identifying the lands to be within the proposed permit areas, shall be provided. Photo copies or other similar copies are not acceptable unless prior approval is obtained from the Land Quality Division.