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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 this form. <br /> Applicant: Hall-Irwin Aggregates, LLC By: <br /> Bret Hall, Manager <br /> Dater , 2017 <br /> NOTARY FOR PERMIT APPLICANT <br /> STATE OF COLORADO <br /> COUNTY OF WELD ) <br /> The foregoing was acknowledged before me this a7 + day 017, by Bret Hall as <br /> Manager of Hall-Irwin Aggregates, LLC, the Applicant. <br /> DONNA M KRAFT <br /> Notary Public Omvz.' <br /> (seal) State of Colorado Notary Public <br /> My Commis i Notary l�#}.g94A021059 <br /> P( ss400cr�ires 12-05-2020 <br /> SIGNATURE OF STRUCTURE OWNER <br /> Structure Owner: MIRIAM RUTH FIRESTIEN REV TRUST Signature: <br /> Date: G' 7 Title: "ri <br /> NOTARY FOR STRUCTURE OWNER <br /> STATE OF COLORADO ) <br /> COUNTY OF WELD ) <br /> The foregoin was cknowledged before Me,this day of ''��-� , 2017, by <br /> U v ►' as of <br /> NICOLE DUESLER <br /> NOTARY PUBLIC <br /> STATE OF COLORADO / <br /> NOTARY ID 0 20164047293 / <br /> MY CO MISSION EXPIRES OECamoVt 09,2019 <br /> Notary Public <br /> My Commission expires: ) c I <br />