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-2- <br />This form has been approved by the Mined Land Reclamation Board pursuant to sections 34-32-119, C.R.S., of the <br />Mined Land Reclamation Act and 34-32.5-119, C.R.S•, of the Colorado Land Reclamation Act for the Extraction of <br />Construction Materials. Any alteration or modification of this form shall result in voiding any permit issued on the <br />altered or modified form and subject the operator to cease and desist orders and civil penalties for operating without a <br />permit pursuant to sections 34-32-123, C.R.S., of the Mined Land Reclamation Act and 34-3Z5-123, C.R S., of the <br />Colorado Land Reclamation Act for the Extraction of Construction Materials. <br />Applicant and Successor hereby request the State to consent to the assignment of the approved Permit Application <br />to recognize the Successor as the approved Applicant under the permitting process. <br />r <br />DO-0-:CL <br />Name of Pertnit Applicant Name of Successor App icant <br />A <br />By By <br />Signature of Officer ignature o Officer <br />Title of Officer Title of Officer <br />NOTARY FOR PERMIT APPLICANT <br />STATE OF L'aL ) <br />) ss. <br />COUNTY OF La. ) <br />The fore ping instrument was acknowledged before me this day of AM-WE-1;7-, by <br />id as ' Dii--` of <br />(.tom U 1 G?44 G i 'L i--C ' <br />`---` O ARY BLIC My Commission expires:' -••• o, <br />,`,• ; <br />NOTARY FOR SUCCESSOR APPLICANT ;`® p!- <br />) <br />STATE OF 00 ?b /'0- e-& <br />ss. <br />COUNTY OF ) <br />= ?'Z ` <br />- 0 _ <br /> ?? <br />. <br /> . <br />.................... <br /> '\ <br />STA?SO <br /> N. <br />Jhhe <br />foregoing instrument was acknowledged b fore a this ? day of / sf bby <br />fe r as dE'A4 of D("S (Q S(? 610"'a J ?C <br />AR Y PG NOTARY PUBLIC <br />p ,,... <br />' GFN :n My Commission expires: <br />?ECHA <br />pF CK010