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~o,ae I OFFICE GF TriE ST:, i c ci 1GiNEcn <br />j , • I ata Cnmonmm mag., i3t~ =ne ~. uanvn., ~_o~ar Ica ec~~~ i <br />__~ i_071 '. Ui~.L71 ~ <br />~~ FSIOR TO CGMPI_~ilfiG FCFM, SEE INSTnUCTIONS ON FE`/ERSE SICE <br />CHANGE 1N OWNERSHIP /ADDRESS <br />WELL PERMff, WESTOCK TANK OR EROSION CONTROL DAM <br />1. NE'N OWNER <br /> NAME(S) rolow~ro Coal Comoanv <br /> Mailing Address 5731 State Highway 13 <br /> City, St. Zip Meeker, Colorado 81641 <br /> Phone 03 824-4451 <br />2. THIS CHANGE IS FOR ONE OF THE FOLLOWING: <br /> WE'LL PERMIT NUMBER 135488 <br /> ^ LIVESTOCK WATER TANK NUMBER <br /> ^ ERO <br /> SION CONTROL DAM NUMBER <br />3. WELL LOCATION: COUNTY Moffat OWNER'S WELL DESIGNATION A-3 <br /> 14 Inverness Drive Eas[, Bldg. F Suite 228, Englewood, Colorado 80112 <br /> (Addra.a) (o~ql (State) 1201 <br /> ~,W 1/4o~tne X1/4, Sec. l l Twp. 3 ^ N. «^ S., Range 93 ^ E. o~ ^ 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 />•>•. LIVESTOCK TANK OR EROSION CONTROL DAM LOCATION: COUNTY <br /> t/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 tar the following reason(s): <br /> Change in name of owner. ^ Change in mailing address. <br />E. 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 Section 24-i-10a (13)(a) C.A.S., the making of false statements herein constitutes perjury in <br /> the second degree and is punishable as a class 1 misdemeanor.] <br />NamerTitle (Please type or print) Signature Date <br />FOR OFFICE USE ONLY <br />I <br />,tea _n;ine.rr <br />ev <br />C.ne <br />,...r Casz Plc. Civ. C~. `NC Basin !,1^ ~ ~;_ <br />