2018-07-16_REVISION - M1998103

• Permit No: M1998103
• IBM Index Class Name: REVISION
• Doc Date: 7/16/2018
• Doc Name Note: Request for Conversion
• From: Town of Limon
• To: DRMS
• Type & Sequence: CN1
• Email Name: PSH
• Email Name: MAC
• Media Type: D
• Archive: No

located on or within 200 feet of the proposed affected area described within Exhibit A, of the
reclamation Permit Application for Patty's Pit, File Number M1998-103.
This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its
authority under the Colorado Land Reclamation Act for the Extraction of Construction Materials
and the Colorado Mined Land Reclamation Act for Hard Rock,Metal, and Designated Mining
Operations. Any alteration or modification to this form shall result in voiding this form.
NOTARY FOR PERMIT APPLICANT
ACKNOWLEDGED BY:
Applicant Representative Name
Date Title
STATE OF )
COUNTY OF )
The foregoing was acknowledged before me this day of 20 , by
as of
My Commission Expires:
Notary Public
NOTARY STRUCTURE OWNER
ACKNOWLEDGED BY:
Applicant Representative Name
Date Title
STATE OF )
COUNTY OF )
The foregoing was acknowledged before me this day of 20 , by
as of
My Commission Expires:
Notary Public
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