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?ur <br />YI <br />'o~ <br />Pur <br />Mo <br />Dat <br />Pur <br />Rer <br />WEI <br />Dat <br />Sta• <br />Len <br />Sus <br />Pun <br />Rer <br />CONTRACTORS STATEMENT <br />The undersigned, being duly sworn upon oath, deposes and says that he is the contractor of the well or <br />pump installation described hereon;. that he has read the statement made hereon; knows the content <br />thereof, and that the"same is true of his own knowledge. . <br />Signature <br />License No. ~ L_ <br /> <br /> <br />J <br />State of Colorado, County of ~.c~a- l_-G~-~-._. SS <br />Subscribed and sviorri to before me this o! day of , 19 <br />My Commission expires: r """ ' T9'_ . <br />Notary Public ~~~ ~• <<~O=_; <br />FORM TO BE MADE OUT IN OUADR VPLICATE: WHITE FORM must be an or~g~nal copy on both aides and s~9ned. <br />WHITE AND GREEN conies must be filed with the State Enp~neer. PINK COPY ~s for the Owner antl VELLOW COPV is for the Dri~ler <br />