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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 f r <br /> Applicant: Hall-Irwin Aggregates, LLC By: 7/ <br /> Bret Hall, Manag <br /> Date call , 2017 <br /> NOTARY FOR PERMIT APPLICANT <br /> STATE OF COLORADO ) <br /> COUNTY OF WELD ) <br /> The foregoing was acknowledged before me thisOilay oc.l. , 2017, by Bret Hall as <br /> Manager of Hall-Irwin Aggregates, LLC, the Appli ant. (�JJ <br /> L <br /> DONNA W*leiAFT Notary Public <br /> IVApaninfiroisliiion expires: I -5-o 6 <br /> State of Colorado <br /> Notary ID#19964021059 <br /> My Commission Expires 12-05-2020 SIGNATURE OF STRUCTURE OWNE• .--- - <br /> Structure Owner: AURORA CITY OF Signature: <br /> /� <br /> Title: �a / � .� I/ <br /> Lid LC. J7 �.¢ , :� I'�.' -e,�c,�.�,� .(��2.st�CZ..- d Lft2kc�.�G l Jf(�C-sem <br /> uu�� oma- V <br /> NOTARY FOR STRUCTURE OWNER <br /> STATE OF COLORADO ) <br /> COUNTY OF WELD ) <br /> The foregoing was acknowledged before me this LPday of---L-A,rte., 2017, by <br /> N seN0.r\A r ck 7 C-)01/4-ii._ as t-Q( �1 G`P�..i\e - of <br /> wet-Vex- SS C . <br /> cc1kc <br /> (seal) Notary Public <br /> My Commission expires: -7 -a(8- )I) <br /> LEIANA BAKER <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID*20014021606 <br /> MY COMMISSION EXPIRES JULY 28,2017 <br />