Free 51893.pdf - Indiana

APPROVAL FOR SELF-BONDING
State Form 51893 (2-05)

INDIANA DEPARTMENT OF NATURAL RESOURCES DIVISION OF RECLAMATION

INSTRUCTIONS: 1. To be completed by Division of Reclamation

Applicant: Guarantor (if applicable): Amount of Self-Bond Approved: Self-Bond Number:

A Rider to Self-Bond Indemnity Agreement and Absolute Corporate Guaranty shall be submitted to identify specific permit and amount where self-bond will be applied.

Accepted:

Date

Director, Indiana Department of Natural Resources

Date

Director, Division of Reclamation