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Form STATE OF COLORADO <br />No. OFFICE OF THE STATE ENGINEER <br />GWS-11 g18 Centennial Bldg., 1313 Sherman St., Denver, CO 80203 <br />/2006 Phone -Info: (303) 866-3587 Main: (303) 866-3581 <br />Fax: 303 866-3589. htt ://www.water.state.co.us <br />CHANGE IN OWNERSHIP/ADDRESS <br />CORRECTION OF THE WELL LOCATION <br />Review instructions on the reverse side prior to completing the form. <br />Name address and phone of the person claiming ownership of the well: <br />NAME(S): Hayden Gulch Terminal, Inc. <br />Mailing Address: 701 Market Street, Suite 700 <br />City, St. Zip: St. Louis, MO 63101-1826 <br />For Office Use Only <br />Phone 314 342-3400 <br />This form is filed by the named individual/entity claiming that they are the owner of the well permitted as referenced above. <br />This filing is made pursuant to C.R.S. 37-90-143. <br />WELL LOCATION: Well Permit Number: 183451 Receipt Number: 0375530 <br />County Routt Owner's Well Designation (optional) HGDAL-3_ <br />(Address) <br />(City ) <br />(State) (Zip) <br />SE1/4 of the SW 1/4, Sec. 14, Twp. 6 ®N. or ^ S., Range 88 ^ E. or ®W., 6th P.M. <br />bdivision Name <br />1000 Ft. From ^ N. or ®S., 1880 Ft. From ^ E. or ®W. Line. <br />Lot ,Block ,Filing/Unit <br />The above listed owner(s) say(s) that he, she (they) own the well described herein. The existing record is being amended for <br />the following reasons: <br />® Change in name of owner ®Change in mailing address ^ Correction of location for exempt wells permitted prior to May <br />8, 1972 and non-exempt wells permitted before May 17, 1965. <br />Please see the reverse side for further information regarding correction of the well location. <br />I (we) claim and say that I (we) (are) the owner(s) of the well described above, know the contents of the statements made <br />herein, and state that the are true tom our knowled e. <br />Signat (s) of the ne o ner P ase Qrint the igrt~is N e & Title Date <br />l~ r I~a.~- ~ Uvs~t <br />1~~~,~ <br />It is a esponsibility of t e new caner of this well to complete d sign the form. Signatures of agents are acceptable if an <br />on in letter of a enc si ned the owner is attached to the form u on its recei t. <br />For Office Use Only <br />State Engineer <br />By Date <br />-16 <br />