Form Amended OSM-1 Form Amended OSM-1 Form Amended Coal Reclamation Fee Report

'-­

I:/~l

(2) inherent

$

/(J

total

c. Rate

e. Ratc

Approved by OMS, n",

Signature

1()2')-()06~,

Expires 111201

Print in ink or type thl.' nalll,' c)frellOl'lIllg person, corporate officer, agent or director
on behalf of the OpCl'Ulnr nr the' !'crll1illce,

Date

I hcreby certify that the stCltCJl1ents made herein lire true, complete and
correct to the best of my knowledge and belief and are made in good faith.

$

minus

plus

D

wire transfer

check

'-­

My commission expires

_______________ . 20

Notary Public signature

_ _ dayof

(seal)

to your original filing on the back of this fOl'm.­

$

Calculated fee:

D+
D -

Entcr the difference between A and B:

Block C

or _4th quarter,

Subscribcd and sworn to before me in my presence the

Plcase cxplain thc

'-

(Vo

%

%

-

number

'-­

Ipnhn,.,p

Contact name

State

Mine name

MSHA number

Pennit numbcr

Master Entity number

Repol1ing for _ I st, _2nd,

,---­

tonnage below:

f. Calculated fee $

d. Net tons

d. Net tons

f. Calculated fee S

c. Reduced tons

(3) exccss

(2) inherent

( I)

b. Moisture

a. Gross tons

c. Reduced tons

(3) excess

(I)

total

'-­
D'

b. Moisturc

a. Gross tons

Block B
Enter am mended

tonnage below:

Enter originally

rpn,wtpd

Block A

Office of Surface
Reclamation and Enforcement
P.O. Box 979068
St. Louis, Mo 63197 -()()OO

Use this fom) to change an US:'v1-1 report already submilled.
Send this foml with any
docU111cntatioll
with
a check or wire transfer for
fccs to:

Coal Recla mation Fcc Report

Amended OSM-l