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.•.• . <br />. ~ ; <br />STATE OF COLORADO For o(fio. u.. o++~y <br />, <br />, dreg O~IOE OF THE STATE ENGJNEEA <br /> ` e,e Cw~rr~Ml 8-do.. 19t9 ~lwnwrn at.. L'«+wr. ~~ 8oz03 ~ ~,~1f'~ )~~ t j <br />T'!~ <br />. . <br />(aaxl ~~ <br />. <br />` PRIOR TO COi+APLE'ftNG FORM. SEE jNSTRt}C110N5 O1~i REVERE-SIDE ~ ~ ,~ <br />: <br />'~ CNAN~~~ [~! i~~1/N~F~SHIP / ~A.D~7RESS <br /> {iy~,LF'l~i.'4itT~ L'h~TAP~K OR E3~O:s~ONCONTROLDAhi _. ._ ._ _.c~y~~ . <br /> 1, CUR QYVNE~i .:. <br /> NAtvl>=(S} Haud 7er~n 1, Inc. _ - <br /> Mailing Addra~ 13©0 South Yale <br /> City, sL zlp Fla staff Arizona Sfi041 <br /> Prone 6t 02 .) 77A-5253 ---- --- ... ,_. <br /> 2 Ti-i1S CNANf3E IS t=OR ONE QF THE Ft7~2~Nt~: . <br /> WEU. pERMiT NUMBER 24ra76-F . <br /> L.1V!"STOCK WATI~ TANK NUMBER . <br />L,J EROStt7N CQNTROI. DA141 NUMBER •• <br />~, WELL I~QcA~tor~; COuN't'Y,_Rout,~, _ owN~'s w131- CESIC~NATION H- G Sh a 11 ow We I 1 <br />Hayden Colors o <br />. _~_i 14 er te. N F. 1 /4~ 1 d TL~Ip'--,,, 6 - ~ N. or ~ S.. R~InBA $S L..J E or ~ W. 6t_ h~P.t~ <br />[~ ^ 8. tlna. 3244 Ft. trcm ^ E a ~ w. Line. <br />Qistances fram-~~on~ 1~...~ from N. ~ ----. • <br />~ 81cc~c___ Filing N~)__ <br />Sttt3dlvisirsn ---'- <br />4, t i~~t3-t'pCIC TANK OR,~OStON CONTAQ AM ~OCA~-O~ COUNTY <br />E,._t N. a ^ S., Range ~ E a ~ W. P.M. <br />114. Sec. T'~• <br />5. The abvvM G4ted owner(s) say(s) that he {they} own tt-e struc~urs dea<xibed h+~rain. <br />The frig record is Ming amended fCr th+e ioua~irtg reasons>: <br />phange In name of owner.. ~ Ctzaroge In malting address. -- <br />6. t (we) have read the statemerrts made h~r~n, know tha concerns thereci, and state thsti tn~y are true . <br />to my {our} imcwledge. of isles statements herein constitutes perjury iR <br />[Pursuant to 9ealicn 2~-104 {t3}(aj C.R.S.. the malcir'+A <br />the sacarod degree and is punist'tabie as a class 1 misdemeanor.] Data <br />NarnelT~a (Please type ~ P"~) Signature <br />Dennis 1.. Stevenson, 12/15/92 <br />•President <br />FOR OFFICE USE ONLY <br />ACCFpTED FOR A Ct'iANGE 1N bWAi>:RSHiP,,-O~L-Y <br />Court Case No. piv..,,.~„r. CQ. ~~~. ~'n------~ MDR,.,.. Use - <br />MR-16 7-5.2 Revised 11/07 <br />