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JUN-01-2009(MON) 11:29 FIRST SOUTHWEST BANK <br />-2- <br />(FRX)9705653399 P.003/004 <br />Thisform has been approved by the Mined land Reclamation hoard pursuant to sections 34-32-119, CRS., of the <br />Mined Land Reclamation Act and 34-32.5-119, GALS., of rite Colorado Land Reclamation Actfor the ,Emraction of <br />Construction Material.. Any ullerullan or modification of this form shall result in voiding any permit lcsued nn th4? <br />altered or ntodiftee forrtt and subject the operator to cease and desist orders and civil penalties for operating without a <br />permit pursuant to sections 34-32-1-73, C R_S., of the Mined Land Neclamation Act and 34-32.5-123, CRS., of the <br />Colorado Land Reclamation Act for the.F,xlruciiun of Construction Materials. <br />Applicunt and Successor hcrcby request the Statc to consent to tljc d5:sigruitcnt of all approval Pcm?t Applka.dun <br />to recognin the Successor as the approved Applicant under the permitting process- <br />Name of Permit Applicant <br />.y <br />Signature of Officer <br />Name of Successor Applicant <br />c <br />By - <br />Signature of Office <br />Title of Officer <br />? 2-" L?- <br />Title ofOflicer <br />NOTARY FOR PERMIT APPLICANT <br />STATE OF CQ?Qrac\o <br />ss. <br />COUNTY Or M o n u rr, <br />The foregoing instrument was acknowledged before me this _ _. .. __ day of by <br />[ eQ.a1e.`., LLC of <br />NOT 6Y P LIC = <br />My Commission expires--a - 26 I o?_ <br />NOTARY FOR SUCCESSOR APPLICANT <br />STATE OF ?IJ?O r'4.0 1 <br />COUNTY OF <br />??r? r_Urn0. 1 <br />The foregoing instrument was acknowledged before me this day of , s U VI Q- . . D9 , by <br />-- tl? J() <br />NOT Y f LIC Y" <br />My Commission expires: "011-qi-)l D -