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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 thi form. <br /> Applicant: Hall-Irwin Aggregates, LLC By: t <br /> Bret Hall, Manager <br /> Date: ' � 2017 <br /> NOTARY FOR PERMIT APPLICANT <br /> STATE OF COLORADO ) <br /> COUNTY OF WELD ) <br /> The foregoing was acknowledged before me this ay 7, by Bret Hall as <br /> Manager of Hall-Irwin Aggregates, LLC the Applicant; <br /> DONNAM KRAFT <br /> Notary Public �^ _ <br /> State of Colorado <br /> (se9�btary ID#19964021059 Notary Public <br /> My Urigr8ir5 i res 12-05 2020 <br /> SIGNATURE OF STRUCTURE OWNER <br /> Structure Owner: J ANTHONY& LISA D ANTUNA Sign , ure. <br /> Date: ,1.,^ - Zo 12.0-4-1 Title: <br /> NOTARY FOR STRUCTURE OWNER <br /> STATE OF COLORADO ) <br /> ) <br /> COUNTY OF WELD <br /> The foregoing was acknowledged before me this Zolay of TVA , 2017, by <br /> S. 19Yi�wr►un�-vn L r as w�i�� of <br /> SZ? C (xLI rZ �'�z1z� <br /> (seal) Notary Publ <br /> My Commission expires: <br /> A;;'W;MUS COX <br /> NOTARY PUBLIC-STATE OF COLORADO <br /> My lden*don 0 20154025611 <br /> Eoies June 30,2019 <br />