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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 his Lorm. <br /> Applicant: Hall-Irwin Aggregates, LLC By: <br /> Bret Hall, Manager <br /> Date. I 12017 <br /> NOTARY FOR PERMIT APPLICANT <br /> STATE OF COLORADO ) <br /> COUNTY OF WELD ) <br /> The foregoing was acknowledged before me this 10 -" ay o 2017, by Bret Hall as <br /> Manager of Hall-Irwin Aggregates, LLC,the Applicant. <br /> DONNA M KRAFT <br /> Notary Public <br /> tatpp of Colorado Nota Public <br /> Notts#19964021059 rY <br /> K"fGmmraisskjhi2 c a-lg-05-2020 <br /> SIGNATURE OF STRUCTURE OWNER <br /> Structure Owner: GLENN S& ROBERTA SMITH Signature: <br /> Date: Title: <br /> NOTARY FOR STRUCTURE OWNER <br /> STATE OF COLORADO ) <br /> COUNTY OF WELD ) <br /> The foregoing was acknowledged before me this day of 4 2017, by <br /> �r ;�A-: as of <br /> i v <br /> (seal) Notary Nub* <br /> My Commission expires: <br /> RONDA E. PALOMINO <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20104010778 <br /> MY COMMISSION EXPIRES MARCH 25, 2018 <br />