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t <br />'u ri <br />ryr <br />'ov <br />Sur <br />Vlo1 <br />)at <br />to r <br />3er <br />VEt <br />)at <br />;ta- <br />_er <br />pus <br />'un <br />Rer <br />CONTRACTORS STATEMENT <br />The undersigned, being duly sworn upon oath, deposes and says that he is the contractor of the well or <br />pump installation described hereon; that he has read the tement made hereon; knows the content <br />thereof, and that the same s true of s own ledge. <br />G <br />Signature License No. <br />State of Colorado, County of fJ L?9 SS <br />Subscribed and sworn to befor me this/-,2_ day of v , 19 ` <br />My Commission expir , 19 <br />Notary Public <br />FORM TO BE MADE OUT IN QUADRUPLICATE: WHITE FORM must be an original copy on both sides and signed. <br />WHITE AND GREEN copies must be filed with the State Engineer. PINK COPY is for the Owner and YELLOW COPY is for the Driller.