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c•.vs~,t ~ STATE OF COLORADO For olfiae uu only <br />io;es OFFICE OF THE STATE ENGINEER <br /> 816 Centennial Bldg., 1313 Sharman SL, Denver, Colorado 60203 <br /> (303) 866-9561 <br />PRIOR TO COMPLETING FORM, SEE INSTRUCTIONS ON REVERSE SIDE <br />CHANGE IN OWNERSHIP /ADDRESS <br />WELL PERMff, LNESTOCK TANK OR EROSION CONTROL DAM <br />1. NEW OWNER <br /> NAME(S) Colowyo Coal Company <br /> Mailing Address 5731 State Highway 13 <br /> City, St. Zip Meeker, Colorado 81641 <br /> Phone (303 ) 824-4451 <br />2. THIS CHANGE IS FOR ONE OF THE FOLLOWING: <br /> D WELL PERMIT NUMBER 135488 <br /> ^ LIVESTOCK WATER TANK NUMBER <br /> ^ EROSION CONTROL DAM NUMBER <br />3. WELL LOCA710N: COUNTY Moffat OWNER'S WELL DESIGNATION A_3 <br /> 14 Inverness Drive East, Bldg. F Suite 228, Englewood, Colorado 80112 <br /> (Addreu) I~tNI (Stale) 2P) <br /> Sl+ 114 or me E 1/4, Sec. 11 Twp. 3 ~ N. or ^ S., Range 93 ^ E. or ®W. 6 P.M <br /> Distances from Section Lines 900 FL from ^ N. or ©S. Line, 1975 Ft. from ®E. or ^ W. Line. <br /> Subdivision Lot Block Filing (Unit) <br />4. LIVESTOCK TANK OR EROSION CONTROL DAM LOCATION: COUNTY <br /> 1/4, Sec. Twp. ^ N. or ^ S., Range ^ E. « ^ W. P.M. <br />5. The above listed owner(s) say(s) that he (they) own the structure described herein. <br /> The existing record is being amended for the totlowing reason(s): <br /> Change in name of owner. ^ Change in mailing address. <br />6. I (we) have read the statements made herein, know the contents thereof, and state that they are [rue <br /> to my (our) knowledge. <br /> [Pursuant to Section 24-4-104 (13)(a) C.R.S., the making of false statements herein constitutes perjury in <br /> the second degree and is punishable as a class 1 misdemeanor.] <br />Name>Ttle (Please type or print) Signature Date <br />FOR OFFICE USE ONLY <br />Stye Engineer By Dete <br />Court Case No. Div. Co. WD Basin MD Use <br />