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. r <br /> <br />-5- <br />C~ <br />4. I understand that statements in the application are being made under penalty <br />of perjury and that false statements made herein are punishable as a Class 1 <br />misdemeanor pursuant to Section 18-8-503, C.R.S. <br />Signed and dated this _~_ day of _~'11~L•tt1~ q3 <br />f^offat County Road ~epartirent <br />Applicant/Operator <br />By: By: <br />Title: <br />State of Colorado > <br />ss. <br />County of Moffat > <br />If Corporation Attest (Seal) <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoing instrument was acknowledged before me this g~ day of March ,lgg~ <br />by Warren J. Conn~n as a~,r Suiarviser ~ of Moffat County <br />Notary Public <br />My Commission Expires: 3-.2-45 <br />2823E (02/05/93) <br />