PERMFILE107596

• Permit No: M1993035
• IBM Index Class Name: Permit File
• Doc Name: APPLICATION FOR A REGULAR 112 MLR PERMIT
• Media Type: D
• Archive: No

-5-

4. I.understand that statements in the application are being made under penalty
of perjury and that false statements made herein are punishable as' a Class 1
misdemeanor pursuant toHS~ection 18-8-503, C.R.S.
~j
Signed and dated this ,~% day of /' , /~% ~.
~/~i~~ ~~,~ Gam.
AppT
By:
Ti tl
If Corporation Attest (Seal)
Corporate Secretary or Equivalent
Town/City/County Clerk
State of >
-7~ , > ss.
County of ~ / ~. e~ )
The foregoing instrument was acknowledged before me this 1~ ~ of t~~ r~/ . %~1~
by I' , ~ t'~ as ,P'I'E/~~l of ~~~/`1~~~lU' . .
_ l~
Notary Public
My Commission Expire,~Cbmmiss.c; i:;,;;~s~,~,~p,
(04/92) 2823E