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Pur <br />TyF <br />Pov <br />Pun <br />Mo' <br />Dat <br />Pun <br />Rer <br />WEl <br />Dat <br />Stagy <br />Len <br />Sus' <br />Pun <br />Rer <br />State of Colorado, County of <br />Subscribed and sworn to before me this ~~'day of <br />My Commission <br />Notary Public ~ <br />License No. fo~ <br />• <br />i <br />CONTRACTORS STATEMENT <br />The undersigned, being duly sworn upon oath, deposes and says that he is the contractor of the well or <br />pump installation described hereon; that he has read the statement made hereon; knows the content <br />thereof, and that the same is true of his own knowledge. <br />