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w;o~ i CFnCE Gr TrE Si.,lc E:~:cJ..:~_.~ <br />~~ tl10 •_yn'annial ? 1, L' ES.• G!nvnr ^„ICr?r~ ~ - <br />~ ~ <br />~: •• <br />~ 1~0~1 dE 57551 • <br />'. PF.IOR TO COMPLETING FORM, SEE INSTFUCTiONS GN RE'/EASE SIDE <br />CHANGE IN OWNERSHIP /ADDRESS <br />WELL PERMIT, WESTOCK TANK OR EROSION CONTROL DAM <br />1. NEON OWNER <br /> NAME(S) Colowyo Coal Company <br /> Mailing Address 5731 State Highway 13 <br /> City, St. Zip Meeker, Colorado 81641 <br /> Phone (~n~ ) R24-4451 <br />2. THIS CHANGE IS F•JR ONE OF THE FOLLOWING: <br /> WELL PERMIT NUMBER <br /> ^ LIVESTOCK WATER TANK NUMBER <br /> ^ EROSION CONTROL DAM NUMBER <br />3. WEL LOCATION: COUNTY Rio Blanco OWNER'S WELL DESIGNATION A-6 <br /> 14 Inverness Drive East, Bldg. F Suite 228, Englewood, Colorado 80112 <br /> (Mdreee) (~IN1 (Swel CGPI <br /> NW 1/4 otm. NE ~/4 <br />28 Twp. 3 ^ N. «^ S <br />6 P <br />Sec <br />Range 93 ^ E <br />M <br />~ W <br /> , <br />. <br />., <br />. « <br />. <br />. <br /> Distances from Section Lines 800 FL from ®N. or ^ S. Line, 1500 Ft. from R^ E. « ^ W. Une. <br /> Subdivision Lot Block Filing (Unit) <br />4. LIVESTOCK TANK OR EROSION CONTROL DAM LOCATION: COUNTY <br /> 114, Sec. Twp. ^ N. «^ S., Range ^ E. «^ W. P.M. <br />5. The above listed owner(s) say(s) that he (they) own the structure descrihed 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 />fi. 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~-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 t misdemeanor.] <br />Name>Ttle (Please type or print) Signature Daze <br />i FOR OF~iCE USc ONLY <br />Stue Engmc,r By =.. + <br />/) <br />~~OUrt Gast NO. Div. GJ. V';. =J_. `.'."' Use i~ <br />- - i <br />