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-2 - <br />This forst has been approvetl by the tlafined Lard Reclatuatiott Board pursuant to sections 34-32-119 C.R.S, oj'tlre <br />Mi►rerl Land Reclanratiou Act and34-32,5 C R.S., oj'the Colorudo Lrrnd Recla►natiou Act for the E_ettactio►r of <br />Cotrstrtrction Materials. Any alteration ot• ►nodifrcation of this fo► s►r shall j esrrlt i►r t,ojding (MY per"'it issued ou the <br />altered or modified fora, acrd subject the operator to cease and desist orders and cirilpef►aides for (1eratilrg rtiitltout rt <br />pe►•t►tit purcr►a►tt to sections 34-32423, C.R.S., of the Mined Land Reclamation Act and 34-32.5-123, C.R.S., of the <br />Colorado Land Reclantation Actfor rile Extraction of Coristr►rctiott Materials. <br />Applicant and Successor hereby rcqucst the Statc to consent to the assignment of the approvcd Permit Application <br />to recognize the Successor as the approved Applicant under the permitting process. <br />Name of Permit Applicant <br />By <br />Si at Officer <br />bl4n." <br />Title of Officer <br />� <br />Name of Successor Applicant <br />By <br />Signature of Officer <br />Title of Officer <br />NOTARY FOR PERMIT APPLICANT <br />r <br />STATE OF <br />)ss. <br />COUNTY OF <br />The foregoing instrument was acknowledged before me this ;day of �f'-ck-1qby <br />as Cl of <br />I�C.�,iy*`� �CsrSlti'L��C �Otl <br />ANGELA MURPHY <br />NOTARY PUBLIC <br />STATE OF NOTARY 0 COLORADOl 4024445 <br />MY Commission Expires 060¢20$1 <br />� r L <br />NOTARY. ' SLIC <br />My Commission expire. <br />NOTARY FOR SUCCESSOR APPLICANT <br />STATE OF } <br />COUNTY OF <br />} <br />The foregoing instrument was acknowledged before nie this �W day of <br />S67 <br />as of <br />NOTARY Ir <br />La , oLo , by <br />cNo acv � XLEN,e, ' <br />S7grE �F C UBLIC MY Commission expires: <br />NOTARY Ip 2Q LORgOp <br />MY Cnm+tiission Expires 01 31 zea <br />