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r <br /> This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its <br /> authority under the Colorado Land Reclamation Act for the Extraction of Construction Materials <br /> and the Colorado Mined Land Reclamation Act for Hard Rock, Metal, and Designated Mining <br /> Operations. Any alternation or modification of this form shall result in voiding this form. <br /> Applicant: Hall-Irwin Aggregates, LLC By: <br /> Bret Hall, Manager <br /> Date: , 2017 <br /> NOTARY FOR PERMIT APPLICANT <br /> STATE OF COLORADO ) <br /> ) <br /> COUNTY OF WELD ) <br /> The foregoing was acknowledged before me this; / i of(4�17, by Bret Hall as <br /> Manager of Hall-Irwin Aggregates, LLC,the Applicant. <br /> DONNA M KRAFT <br /> Notary Public <br /> ��l��� State of Colorado Notary Public <br /> M �SeTYotary 10 0 19964021059 <br /> ry <br /> Y 0ffR�6rkiRf'isQ?fc 63C0ir s 12-05-2020 <br /> SIGNATURE OF STRUCTURE OWNER <br /> Structure Owner: SHARK'S TOOTH PIPE LINE CO Signature: <br /> Date: Title: Presj'c + <br /> NOTARY FOR STRUCTURE OWNER <br /> STATE OF COLORADO ) <br /> COUNTY OF WELD ) <br /> The foregoing was acknowledged before me this23 day ot,I .Ar)c 2017, by <br /> Co. <br /> seal Notary Public <br /> COMM iS@RV c {ER <br /> NOTARY PUBLIC— <br /> STATE OF COLORADO <br /> WARY ID 1"74178013 <br /> MY COMMISSION EXPIRES JUNE 28.2018 <br />