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Pum <br />Typ <br />-'w <br />L~ <br />Mot <br />Date <br />Purt <br />Ren <br />WEl <br />Dat <br />Stat <br />Len <br />o .~, <br />Ren <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 me true of is own knowledge. <br />Signature ~ ~_,~_ _... __-_- License No. <br />State of G6lorado, County of ' _ _ _ SS <br />Subscribed and sworn to before me this _ day of _ _____ 19 <br />My Commission expires' ~_ 19 _ . <br />Notary Public <br />FORM TO BE MADE OUT rN OUA DR UVLICA TE WMrTE FORM mu~r brr ~n original copy on born rrdn and trgned <br />WHITE AND GREEN copwt must be bled mrh me Sure Engmen. PINK COpV n lo. rho Ownrrr and VEELOIV COPY n for W Dnov. <br />