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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 voidigg th' orm. <br /> Applicant: Hall-Irwin Aggregates, LLC By G <br /> Bret Hall, Manager <br /> Date: 12017 <br /> NOTARY FOR PERMIT APPLICANT <br /> STATE OF COLORADO ) <br /> COUNTY OF WELD ) <br /> The foregoing was acknowledged before me this AI day 01 , 2017, by Bret Hall as <br /> Manager of Hall-Irwin Aggregates, LLC, the Applicant. <br /> DONNA M KRAFT <br /> Notary Public ,-" <br /> 'C e of Colorado Notary Public <br /> Nl�tl"y IkND#19964021059 <br /> �m It9ii33i6di1e�opAis:2-o 5-2020 <br /> SIGNATURE OF STRUCTURE OWNER <br /> Structure Owner:DAMES E &SARAH J MUMFORD Signature: 06e'� • <br /> Date: -,23. /7 Title: <br /> NOTARY FOR STRUCTURE OWNER <br /> STATE OF COLORADO ) <br /> ) <br /> COUNTXOF WELD ) <br /> T\h�foregoing was ac nowledged before met isZ&y of�, 2017, by <br /> 1� i6►Q®aCA L' 6&,?_e,[,4 as of <br /> (seal) Not ry Public <br /> My Commission expires: <br /> ............. <br /> VERONICA L.GARCIA <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID#20044017126 <br /> E <br /> COMMISSION EXPIRES 06-12-2020 <br />