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C O L O R A D O Completion of Construction <br />Division of Water Resources DRS-11A (1o.n.2019) <br />" Department of Natural Resources <br />1. Dam Information <br />Name of Dam: Williams Fork Mine 9A-P4 <br />WDID: NA <br />Receipt/Priority Number: �NA <br />OLivestock Water Tank <br />Type of Dam: <br />0Erosion Control Dam <br />Date Construction was Completed: Sept. 1979 <br />2. Location Information <br />• If the location information is different from what was provided on the DRS-11 Application for Livestock Water Tank <br />and Erosion Control Dam, please update the PLSS or GPS Location information below. <br />• To determine the location information, please use the Location Spotter at: <br />https• //dwr.sLate.co.us/TooLs/LocationConverLer <br />PLSS <br />Q40 Q160 Section Township Range PM County <br />SE SW 30 6.0 (�)N OS 91.0 OE(�)W Moffat <br />GPS Location <br />• Point taken should be at the crest of the dam above the streamline/outlet <br />• Datum should be UTM, NAD 83 <br />Zone Easting (UTMx) Northing (UTMy) <br />Zone 13 275267.3 4480224.9 <br />3. Sign and Enter Name of Responsible Individual <br />• Submit the completed form electronically to the State Engineer's Office Online Form Submission Email account <br />DWRPermitsOntine@state.co.us <br />• The making of false statements herein constitutes perjury in the second degree, which is punishable as a class 1 <br />misdemeanor pursuant to C.R.S. 24-4-104 (13)(a). I have read the statements herein, know the contents thereof and <br />state that they are true to my knowledge <br />Sign or Enter Name(s) of <br />Responsible Individuals) <br />If Signing Enter Name and Title <br />Miranda Kawcak, Environmental Manager, Peabody <br />Date <br />3/31 /2020 <br />1313 Sherman Street, Room 821, Denver, CO 80203 P 303.866.3581 www.colorado.gov/water <br />Q�� <br />