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• <br /> 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 ing <br /> Operations. Any alternation or modification of this form shall result in voiding t is -. <br /> Applicant: Hall-Irwin Aggregates, LLC By: -i vI <br /> Date: 9K <br /> 2017 Bret Hall, Mana -r <br /> NOTARY FOR PERMIT APPLICANT <br /> STATE OF COLORADO <br /> } <br /> COUNTY OF WELD CCLL'' <br /> The foregoing was acknowledged before me this 1day of ,2017, by Bret Hall as <br /> Manager of Hall-Irwin Aggregates, LLC,the Applicant. <br /> (seal) Notary Public <br /> My Commission expires: S-0630 <br /> SIGNATURE OF STRUCTURE OWNER <br /> pp I •► <br /> Structure Owner:YOSHI AND SUZ&LLLP Signature:/bah;* ft-2-ft 17 a <br /> Date: 7'2° " r?` Title: 1l-- <br /> �nlet.rk an <br /> NOTARY FOR STRUCTURE OWNER <br /> STATE OF COLORADO ) <br /> COUNTY OF WELD <br /> The foregoing was acknowledged before me this o day of.- "7 , 2017,by <br /> OloP \I: -SS as Chc tr ot&-J of <br /> ( OS qn[ Sta"w'LI—LP . - <br /> (seal) Notary Public <br /> My Commission expires: t3 a41 <br /> SHARON K NI8H IMOTO <br /> NOTARY POMO <br /> STATE OF COLORADO <br /> NOTARY ID 20074026020 <br /> MY COMMISSION EXPIRES JULY 13,2019 <br />