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`a~ ~ CFrICE OF THE STA~t ENGIN ER <br />~ BIB Cumnnrnal dlEg., 117 Sher SC. Canvar, Cobmdo dCd^] <br />(^_071 BfiB~~5d1 <br />PR!CR TO COtdPLETING FORM, SEE INSTRUCTIONS ON R~ /EASE SIDE <br /> CHANGE IN OWNERSHIP /ADDRESS <br /> WELL PEAMff, LIVESTOCK TANK OR EROSION CONTROL DAM <br />1. NE'N OWNER <br /> NAME(S) Colowvo Coal Comoanv <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 /> WELL PERMIT NUMBER t 35483 <br /> ^ LIVESTOC <br /> K WATER TANK NUMBER <br /> ^ <br />R <br /> E <br />OSION CONTROL DAM NUMBER <br />3. WELL LOCATION: COUNTY Moffat OWNER'S WELL DESIGNATION 84-W (84-D1-02) <br /> 14 invernesc nr+va Pgcr Aldo F _ 4~; ~~8 Fn I wood Colorado 8011 <br /> (Aaareee) (C1ry1 (State) (ZVl <br /> rJw 1/4 o1 NS ~r.~~/4, Sec.~~Twp. 3 ©N. «^ S., Range 93 ^ E. or ©W. 6 P.M <br /> Distances from Section Lines 725 FL from ©N. or ^ S. Line, 2300 Ft. from ®E. or ^ W. Line. <br /> St.,re ~a~~ne N-336,175, E-1,359,576 La[ Block Filing (Unit) <br />~. LIVESTOCK TANK OR EROSION CONTROL DAM LOCATION: COUNTY <br /> 1/4, Sec. Twp. ^ N. o. ^ 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 following reason(s): <br /> 0 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 true <br /> to my (our) knowledge. <br /> [Pursuant to Sec:ion 2a-i•t0a (13)(a) C.A.S., the making of false statements herein ccnstitutes perjury in <br /> the second degree and is punishaole as a class 1 misdemeanor.] <br />NamelTitle (Please type or print) Signa[ure Date <br />' FOR OFFICE USE ONLY <br />i <br />i <br />I <br />,I <br />_.... ~.___ .. l=iv. Co. `11D Eason G1D Use <br />