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This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its authority <br /> under the Colorado Land Reclamation Act for the Extraction of Construction Materials and the <br /> Colorado Mined Land Reclamation Act for Hard Rock, Metal, and Designated Mining Operations. Any <br /> alteration or modification to this form shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> Applicant: Colorado Milling Company, LLC, L—YW— <br /> OJ`�Representative Name: Mark A. Steen <br /> Date 5 aOl9ritle: Agen <br /> STATE OFCOLORADO ) <br /> ) ss. <br /> COUNTY OF BOULDER ) <br /> The foregoing was acknowledged before me this n,4, day of January 2019, by <br /> (LIG� A S�e1Z w as Agent of the Colorado Milling Company, LLC . <br /> Lj= <br /> My Commission Expires: v <br /> Notary Public <br /> CEMRAN LAMICNHANE <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTAW 10 MU019C13 <br /> MY COMMISSION emm NNE 29,2MI <br /> NOTARY FOR STRUCTURE OWNER <br /> ACKNOWLEGED BY: <br /> Structure Owner(s) Name(s) <br /> Date Title <br /> STATE OF COLORADO ) <br /> ss. <br /> COUNTY OF BOULDER ) <br /> The foregoing was acknowledged before me this day of 2019, by <br /> as of <br /> My Commission Expires: <br /> Notary Public <br />