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4 <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 forI. <br /> Applicant: Hall-Irwin Aggregates, LLC By: / <br /> Bret Hall, Manager <br /> 4 <br /> Dat , 2017 <br /> NOTARY FOR PERMIT APPLICANT <br /> STATE OF COLORADO ) <br /> COUNTY OF WELD ) <br /> The foregoing was acknowledged before me this S day o 2017, by Bret Hall as <br /> Manager of Hall-Irwin Aggregates, LLC,the Applicant. <br /> DONNA M KRAFT L" <br /> Notary Public Notary Public <br /> (seal)) State of Colorado <br /> My ommi btle�rt-9964021059 <br /> MX Commission Expires 12-05-2020 <br /> SIGNATURE OF STRUCTURE OWNER <br /> Structure Owner: DANA L CHRISTIANSEN Signature: <br /> Date: Title: <br /> NOTARY FOR STRUCTURE OWNER <br /> STATE OF COLORADO ) <br /> COUNTY OF WELD ) <br /> TIC fGregoi .was a knowledged before me this,y_ day of , 2017, by <br /> t 0" "),S VV C-- as S`E'dV C4t-C Gu.1 Fr of <br /> (seal) Notary Public <br /> My Commission expires: <br /> SMELLY L MARTINEZ <br /> NOTARY PUBLIC <br /> iTATE OF COLORADO <br /> NOTARY ID 0 20104043783 <br /> MY COR".IAISSION EXPIRES OCiOSER 15,2016 <br />