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

Notury Public

slgn~tun.:

Subscribed and sworn
of

3rd or

t~l

4th qum1er, 20

(seal)

2.

Signature

5.

4.

$
Total Due

check

electronic funds transfer

----------------------------

----­

$
Credits or Amount
due from previous
filings,

Total Payment S

S
Amount Due:

Check one:

Reporting entity number

Email Address (if available)

-------------------------

----------------------------------

Telephone number

Contact person:

Date

Print in ink or type the name of reporting person, corporate officer, agent or director
on behalf of the operator or the permittee,

I I hereby certify that the statements
correct to the best of my knowledge

cenilkation required in this sectIon shall, upon conviction, be punished by a line of notmol'c than $10,000,

, agent or director, on behalf of a coal mll1C operator who knowingly makes any tllise statements, representa!1on or

I'vly COll1!1li.'''Hl:l expires

before me in mv presence the

Approved by OMB, no. 102').006.1 , Expin:s I 1/20 I

certification. or knowingly
or by imprisonment I()r not

3.

st,

This certificlitioll covers the following permit number(s):

1. Reporting for

Part 1
OSM-l
Coal Reclamation Fee Report

U.S. Department of the Interior, Office of Surface Mining Reclamation and Enforcement

All stockpile reportcd

D

d.

9.

Expires 11/2011

Total calculated fee for this permit number

$ _ _ _ _ _ _ _ __

f. Calculated fee

$

f. Calculated fee

Approved by OMB, no. 1()2')-OIl63

$

e. Rate

$

%

$

f. Calculated fce

$

$

-------­

-­

--'--­

e. Rate

d. Net tons

c. Reduced tons

(3) excess

(2) inherent

%

total - - ' - - ­

(I)

%

b. Moisture

a. Gross tons

j. Taxpayer I.D.

i. Address

h. Operator name

State

st, __2nd, __3rd or ___4th quarter, 20_

'-­

e. Rate

--

d. Net tons

excess

--

d. Net tons

--

--

c. Reduced tons

--

inherent

for

--'--­

6.

c. Reduced tons

excess

inherent

---

( I)

(I)

total

b. Moisture

b. Moisture

total

a. Gross tons

g. Taxpayer I.D.

f. Address

e. Permittee name

Mine Name

a. Gross tons

'--­

Mining complete

D

Tribe

c.

b. County

a. MSHA number

Permit Number

8, Fee Computation

7,

You must 1111 out u Pal1 2 and Part :I for

each permit number YOll are

Part 2 -- Coal Reclamation Fee Report, OSM-l

%

%l

%

loadill~

1'(1111)

Approved by OMB,

lit),

l(i~()-III}".',

Expile> I I

II

State

lfyoll need more space, please atlach additional sheets,

city/state/zip

(pier plant, tippie,

address

14.

Coal delivered to:

city/state/zip

_ _ 3rd or _ _4th quarter,

city/state/zip

1st,

address

RepOliing for

13. I Purchasers of coal

Mine Name

10.

address

Permit Number

of the Abandoned

nllmber you are reporting. This

12. I Mineral owners

II.

a Part .3 for each
infonnation is
Mine Reclamatioll Act of 1990.

Part 3 -- Coal Reclamation Fee Report, OSM-l