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Home My WebLink About20110803.tiffRESOLUTION RE: APPROVAL OF RENEWAL APPLICATION FOR HOTEL AND RESTAURANT LIQUOR LICENSE FROM RJML, LLC, DBA LA MARAVILLA AND AUTHORIZE CHAIR TO SIGN - EXPIRES MARCH 10, 2012 WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, RJML, LLC, dba La Maravilla, presented to the Board of County Commissioners of Weld County, Colorado, an application for the renewal of a Hotel and Restaurant Liquor License, for the sale of malt, vinous and spirituous liquors, and WHEREAS, pursuant to Exhibit 5-H of the Weld County Code, said applicant has paid the sum of $175.00 to the County of Weld for the renewal of the existing license, and WHEREAS, said applicant has exhibited a State Liquor License for the sale of malt, vinous and spirituous liquors for consumption by the drink on the premises only, outside the corporate limits of any town or city in the County of Weld at the location described as follows: 13015 County Road 16 Fort Lupton, Colorado 80621 NOW, THEREFORE, BE IT RESOLVED that the Board of County Commissioners of Weld County, Colorado, having examined said application and the other qualifications of the applicant, does hereby grant License Number 2011-08 to said applicant to sell malt, vinous and spirituous liquors for consumption by the drink on the premises only, only at retail at said location; and the Board does hereby authorize and direct the issuance of said license by the Chair of the Board of County Commissioners, attested to by the Clerk to the Board of Weld County, Colorado, which license shall be in effect until March 10, 2012, providing that said place where the licensee is authorized to sell malt, vinous, and spirituous liquors for consumption by the drink on the premises only, shall be conducted in strict conformity to all of the laws of the State of Colorado and the rules and regulations relating thereto, heretofore passed by the Board of County Commissioners of Weld County, Colorado, and any violations thereof shall be cause for revocation of the license. cam., i3,90 • u -1x-11 2011-0803 LC0044 RENEW LIQUOR LICENSE - RJML, LLC, DBA MARAVILLA PAGE 2 STIPULATED CONDITIONS FOR RENEWAL OF LICENSE (A) The Licensee (which term includes the Licensee, its employees and agents) shall call the Weld County Sheriffs Office and report each incident and person whom the Licensee has reason to believe has violated the Colorado Liquor Code or other state law in the licensed premises, its parking lot, or appurtenant structures. Because the Licensee is encouraged to make these calls, the number of calls made shall not be a basis for revocation or non -renewal of the liquor license. The Board of County Commissioners shall not be constrained from considering the nature of a pattern of calls, the numbers notwithstanding. The Licensee shall provide one (1) parking stall near the front entrance of the licensed premises that will be reserved for a Sheriff's office vehicle. (B) The Licensee shall employ for an additional twelve (12) months a qualified and competent security company that will have free and open communication with the Weld County Sheriffs Office. Thereafter, the need for the security company shall be assessed by the Weld County Sheriffs Office, and the security company may be terminated with the agreement of the Weld County Sheriffs Office. The security guards will work inside the licensed premises and in the parking lot of the licensed premises. All security guards working in or outside the licensed premises shall wear uniform clothing that allows them to be readily distinguished from the patrons. No security guards will carry firearms while working in or outside the licensed premises. (C) Upon renewal, the occupancy level in the dance hall portion of the licensed premises shall be 450 occupants. If the Licensee wishes to further increase the occupancy, he shall install secondary treatment to the existing septic system. After the secondary treatment has been in place for ninety (90) days, the County Health Department shall conduct a review to determine whether the improved septic system is performing adequately and the Weld County Sheriffs Office shall conduct a review to determine whether the increased occupancy level has caused law enforcement concerns. Upon the Health Department's and Weld County Sheriff's recommendations, the occupancy level may be increased to 500 occupants by resolution of the Board of County Commissioners of Weld County. At this point, Church & Associates will provide a progress report regarding the septic system. If there are no concerns expressed by Church & Associates or the Weld County Sheriff, the occupancy level may be increased to 550 occupants. At this point, Church & Associates shall perform a thorough analysis report. If there are no concerns expressed by Church & Associates or the Weld County Sheriff, the occupancy level may be increased to 600 occupants. At each interval, the County Health Department and the Weld County Sheriff shall review their records and recommend approval or denial of each increase. Each increase must first be approved by resolution of the Board of County Commissioners prior to becoming effective. If the County Health Department or Weld County Sheriffs office has any concerns, they shall work with the Licensee to attempt to resolve these concerns. Applicable limits on the number of meals served, restaurant hours of operation, and restaurant methods of service shall comply with the requirements set forth in Board of County Commissioners' Resolution #2004-2245. 2011-0803 LC0044 RENEW LIQUOR LICENSE - RJML, LLC, DBA MARAVILLA PAGE 3 (D) The Licensee shall at all times be in compliance with the Colorado Primary Drinking Water Regulations. (E) The Licensee shall continue to take all necessary steps to assure that minors are not served any alcoholic beverages. These steps shall include providing a secure barrier separating minors from adults in the dance hall as permitted by the Weld County Building Code and serving alcoholic beverages to adults on the "minor side" by "single -serve," only (no beer buckets). The Board finds that the public welfare and morals will not be impaired as long as the Licensee complies with these conditions governing minors present within the licensed premises when alcohol is being served. (F) The Licensee shall continue to host "responsible vendor" training every six (6) months as agreeable to the Colorado Department of Revenue Liquor Enforcement Division, and this training shall be open to other area licensees. Each employee shall be "responsible vendor" trained, and the Licensee shall provide documentary evidence that each employee has been "responsible vendor" trained to the Weld County Clerk to the Board within thirty (30) days of the first available "responsible vendor" class after hiring. (G) The Licensee shall continue to fully fence the trash receptacles and exert its best effort to assure that all trash is placed within a receptacle rather than in bags on the ground outside the receptacle. (H) The Licensee shall continue to provide lighting for the parking lot on the all sides of the licensed premises. The Licensee also agrees to continue to provide two (2) security officers to patrol the parking lot - one in the west lot and one in the east lot B when the dance hall is open. (I) The Licensee agrees to continue to limit use of the dance hall to Thursday, Friday, Saturday and Sunday evenings, all legal holidays as recognized by the State of Colorado, and May 5th and September 16th. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said application. 2011-0803 LC0044 RENEW LIQUOR LICENSE - RJML, LLC, DBA MARAVILLA PAGE 4 The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 28th day of March, A.D., 2011. Weld County Clerk to the BY: Deputy Clerk to the Boar Date of signature: 6/M3/ 1 I BOARD OF COUNTY COMMISSIONERS WELD/SUNTY, CJDJ4JRADO can P. CQ (A. William F. 2011-0803 LC0044 ]�l�J' JC:J�J�J�J��J� JJJJ� JrJ` JJ`��` �r.CMI f iJ %1 .)F sts- W U 1J fr a z H O O F -4 O 0 T T, • 5 O O a, cis w ..d a, et to • ccs ,.S a U w 4, O .n b (. 4 3-4 V) • 0 0 L gri 0 0 ci G C) U) Q.) a, O O U) a, V/ 4-4 0 0 • 6.10 • tic b O 0 a rci 1-4 Cr U) 0 5 : a O E U) 4-1 Ca) I. Ga C4 C CZS O ci W CU rs 0 O 4-4 Cid ,bA a � cta4 -o si O O e M 1-1 O 6.0 N 4-1 t-° CU CO U) ci 0 O C 0 ci • cu ro 0 0 w O v w O N W cts V z s O ro c4 0 V a V) 0 O O 1-4 • CU a, U) U Cn cn cn 1-1 0 0 c-� wo C) ci a 0 A L4-4 O Cti -O H 0 Pt w L4-4 O 0 . Cn 4-4 cu PS ci • U a U) a, ci ci O U w O a, a, 14-1 ci a, 0 U U) a) U) • U) U) a, U) H 'd a, C «i U) a 05 C) 0 b Ct 0 9 4-1 CU O E U) ▪ U U) 1-1 CU a, V) .L 4-1 CU U) 0 (• /) 0 C 0 O b ci o N O 14 O PS 0O Ct 0 x IN C: 0 cn U U b 0 V) C U C U U 4 It L° d-��r�J'-raJ'�C'�C'�C'G'G'-C'-�r�'_G'.G�CJ'_ G�Cos, 4 C 0 4 ( h F C t 1 F 0 4 0 THIS LICENSE MUST BE POSTED IN PUBLIC VIEW DR 8402 (10129(07) DEPARTMENT ALCOHOLIC STATE OF COLORADO OF REVENUE Liquor Enforcement Division 1881 Pierce Street, Suite 108 Lakewood, Colorado 80214 RJML LLC LA MARAVILLA RESTAURANT 13015 WCR 16 FT LUPTON CO 80621 BEVERAGE LICENSE Liability Information Account Number County City Indust. Type Liability Date LICENSE EXPIRES AT MIDNIGHT 40-48501-0000 03 206 722110 B 031103 MAR 10, 2012 Type Name and Description of License Fee 1971 2190 HOTEL AND RESTAURANT LIQUOR LICENSE - MALT, VINOUS, AND SPIRITUOUS COUNTY 85 PERCENT OAP FEE $ 75.00 $ 425.00 TOTALFEE(S) This license is issued subject to the laws of the State of Colorado and especially of Title 12, Articles 46 or 47, CRS 1973, as amended. This license is nontransferable conspicuously posted in the place above described. This license is only valid through date shown above. Questions concerning this license should be addressed to Revenue, Liquor Enforcement Division, 1375 Sherman Street, Denver, CO 80261. In testimony whereof, I have hereunto set my hand. .K) Division Director Executive $ 500.00 under the provision and shall be the expiration the Department of aiti, Director Ruben 4©I-gc10 DR 8404 (05/07/09) Page 1 COLORADO DEPARTMENT OF REVENUE LIQUOR ENFORCEMENT DIVISION DENVER CO 80261 COLORADO LIQUOR RETAIL LICENSE APPLICATION 21 O NEW LICENSE O TRANSFER OF OWNERSHIP LICENSE RENEWAL • ALL ANSWERS MUST BE PRINTED IN BLACK INK OR TYPEWRITTEN • APPLICANT MUST CHECK THE APPROPRIATE BOX(ES) • LOCAL LICENSE PEE $ • APPLICANT SHOULD OBTAIN A COPY OF THE COLORADO LIQUOR AND BEER CODE (Call 303-370-2165) 1. Applicant is applying as a ❑ Corporation O Partnership (includes Limited Liability and Husband and Wife Partnerships) DEPARTMENT USE ONLY m/❑Individual L7 Limited Liability Company ❑ Association or Other 2. Agp icant If an LLC, name of LLC; if partnership, at least 2 partner's names; if corporation, name of corporation 2a. Trade Name of Estgbli hment (DBAJ La (Anvnutl�a 3. Address of Premises (specify exact location of premises t5wpe�1 3. Lack Y\ L� ] — f2J) L / LLC State Sales Tax No. LD4f)t -Deco Fein Number Business Telephone �a3s7-�8a I City tOtt YI 4. Mailing Address ( mber ar0 Street) aJa E,k 2Q1oeC r 5. If the premises currently have a liquor or beer license, you MUST answer the following questions: County We ` 1 Cj1)S or Town Wit LuQ1D n Staa�te��, Co State CO ZIP Code ZIP Code Wcffia Present Trade Name of Establishment (DBA) IZIT & Ur> di la. fltr ottla. LIAB SECTION A NONREFUNDABLE APPLICATION FEES 2300 ❑ Application Fee for New License $1,025.00 2302 ❑ Application Fee for New License - w/Concurrent Review $1,125 00 2310 ❑ Application Fee for Transfer $1,025.00 Present State License No. LIAR SECTION B LIQUOR LICENSE FEES 1905 ❑ Retail Gaming Tavern License (City) $500.00 1906 ❑ Retail Gaming Tavern License (County) $500.00 1940 ❑ Retail Liquor Store License (City) $227.50 1941 ❑ Retail Liquor Store License (County) $312.50 1950 ❑ Liquor Licensed Drugstore (City) $227.50 1951 ❑ Liquor Licensed Drugstore (County) $312.50 1960 ❑ Beer and Wine License (City) $351.25 1961 ❑ Beer and Wine License (County) $436.25 1970 ❑ Hotel and Restaurant License (City) $500.00 1971 ig Hotel and Restaurant License (County) $500.00 1975 ❑ Brew Pub License (City) $750.00 1976 ❑ Brew Pub License (County) $750.00 1980 ❑ Hotel and Restaurant License w/opt premises (City)$500.00 1981 ❑ Hotel and Restaurant License w/opt premises (County) $500.00 1983 ❑ Manager Registration - H & R $ 75.00 Present Class of License k\ and. LIAR SECTION B (CONT.) 1985 ❑ Resort Complex License (City) $500.00 1986 ❑ Resort Complex License (County) $500.00 1988 ❑ Add Related Facility to Resort Complex... $ 75.00 X Total 1990 ❑ Club License (City) $308.75 1991 ❑ Club License (County) $308.75 2010 ❑ Tavern License (City) $500.00 2011 ❑ Tavern License (County) $500.00 2012 ❑ Manager Registration - Tavern $ 75.00 2020 ❑ Arts License (City) $308.75 2021 ❑Arts License (County) $308.75 2030 ❑ Racetrack License (City) $500.00 2031 ❑ Racetrack License (County) $500.00 2040 ❑ Optional Premises License (City) $500.00 2041 ❑ Optional Premises License (County) $500.00 2045 ❑ Vintners Restaurant License (City) $750.00 2046 ❑ Vintners Restaurant License (County) $750.00 2220 ❑ Add Optional Premises to H & R $100.00 X Total 2370 ❑ Master File Location Fee $ 25.00 X Total — 2375 ❑ Master File Background $250.00 X Total _ Present Expiration Date LIQUOR LICENSE FEES DO NOT WRITE IN THIS SPACE - FOR DEPARTMENT OF REVENUE USE ONLY LIABILITY INFORMATION County City Industry Type License Account Number Liability Date License Issued Through (Expiration Date) FROM TO State -750 (999) City 2180-100 (999) County 2190.100(999) Managers Reg -750 (999) Cash Fund Nov License 2300-100 (999) Cash Fund Transits License 2310-100 (999) TOTAL 2011-0803 OR 8404 (05/07/09) Page 2 APPLICATION DOCUMENTS CHECKLIST AND WORKSHEET Instructions: This check list should be utilized to assist applicants with filing all required documents for licensure. All documents must be properly signed and correspond with the name of the applicant exactly. All documents must be typed or legibly printed. Upon final State approval the license will be mailed to the local licensing authority. Application fees are nonrefundable. ITEMS SUBMITTED, PLEASE CHECK ALL APPROPRIATE BOXES COMPLETED OR DOCUMENTS SUBMITTED I. APPLICANT INFORMATION • A. Applicant/Licensee identified. • B. State sales tax license number listed or applied for at time of application. • C. License type or other transaction identified. ❑ D. Return originals to local authority. • E. Additional information may be required by the local licensing authority. II. DIAGRAM OF THE PREMISES • A. No larger than 8 1/2" X 11". • B. Dimensions included (doesn't have to be to scale). Exterior areas should show control (fences, walls, etc.). • C. Separate diagram for each floor (if multiple levels). ■ D. Kitchen - identified if Hotel and Restaurant. III. PROOF OF PROPERTY POSSESSION ❑ A. Deed in name of the Applicant ONLY (or) • B. Lease in the name of the Applicant ONLY. • C. Lease Assignment in the name of the Applicant (ONLY) with proper consent from the Landlord and acceptance by the Applicant. • D. Other Agreement if not deed or lease. IV. BACKGROUND INFORMATION AND FINANCIAL DOCUMENTS ■ A. Individual History Record(s) (Form DR 8404-I). • B. Fingerprints taken and submitted to local authority. (State authority for master file applicants.) ❑ C. Purchase agreement, stock transfer agreement, and or authorization to transfer license. • D. List of all notes and loans. V. CORPORATE APPLICANT INFORMATION (If Applicable) ■ A. Certificate of Incorporation (and/or) ■ B. Certificate of Good Standing if incorporated more than 2 years ago. • C. Certificate of Authorization if foreign corporation. "principal • D. List of officers, directors and stockholders of parent corporation (designate 1 person as officer"). VI. PARTNERSHIP APPLICANT INFORMATION (If Applicable) ❑ A. Partnership Agreement (general or limited). Not needed if husband and wife. VII. LIMITED LIABILITY COMPANY APPLICANT INFORMATION (If Applicable) ❑ A. Copy of articles of organization (date stamped by Colorado Secretary of State's Office). ■ B. Copy of operating agreement. • C. Certificate of Authority (if foreign company). VIII. MANAGER REGISTRATION FOR HOTEL AND RESTAURANT, TAVERN LICENSES WHEN INCLUDED WITH THIS APPLICATION • A. $75.00 fee. • B. Individual History Record (DR 8404-I). DR 8404 (05/07/09) Page 3 6. Is the applicant (including any of the partners, if a partnership; members or manager if a limited liability company; or officers, stock- holders or directors if a corporation) or manager under the age of twenty-one years? Yes No • ,/ CJ 7. Has the applicant (including any of the partners, if a partnership; members or manager if a limited liability company; or officers, stockholders or directors if a corporation) or manager ever (in Colorado or any other state); (a) been denied an alcohol beverage license? (b) had an alcohol beverage license suspended or revoked? (c) had interest in another entity that had an alcohol beverage license suspended or revoked? If you answered yes to 7a, b or c, explain in detail on a separate sheet. • - • e/ • L1T 8. Has a liquor license application (same license class), that was located within 500 feet of the proposed premises, been denied within the preceding two years? If "yes," explain in detail. ❑ e 9. Are the premises to be licensed within 500 feet of any public or private school that meets compulsory education requirements of Colorado law, or the principal campus of any college, university or seminary? �,/ ■ L7 10. Has a liquor or beer license ever been issued to the applicant (including any of the partners, if a partnership; members or manager limited liability company; or officers, stockholders or directors if a corporation)? If yes, identify the name of the business and list current or former financial interest in said business including any loans to or from a licensee. if a any ,�/ • L-14 11. a. Attach entrances, to Does the Applicant, as listed on line 2 of this application, arra in of have legal possession of the premises by virtue of ownership, lease or Detail) other U Ownership ■ Lease • Other (Explain Ownership If leased, list name of landlord and tenant, and date expiration, EXACTLY as they appear on the lease: Landlord Tenant Expires a diagram and outline or designate the area to be licensed (including dimensions) which shows the bars, brewery, walls, partitions, exits and what each room shall be utilized for in this business. This diagram should be no larger than 8 1/2" X 11". (Doesn't have be to scale) 12. Who, besides the owners listed in this application (including persons, firms, partnerships, corporations, limited liability companies), will loan or give money, inventory, furniture or equipment to or for use in this business; or who will receive money from this business. Attach a separate sheet if necessary. NAME DATE OF BIRTH FEIN OR SSN INTEREST Attach copies of all notes and security instruments, and any written agreement, or details of any oral agreement, by which any person (including partnerships, corporations, limited liability companies, etc.) will share in the profit or gross proceeds of this establishment, and any agreement relating to the business which is contingent or conditional in any way by volume, profit, sales, giving of advice or consultation. 13. Optional Premises or Hotel and Restaurant Licenses with Optional Premises Has a local ordinance or resolution authorizing optional premises been adopted? Number of separate Optional Premises areas requested. (See License Fee Chart) Yes No • II 14. Liquor Licensed Drug Store applicants, answer the following: (a) Does the applicant for a Liquor Licensed Drug Store have a license issued by the Colorado Board of Pharmacy? COPY MUST BE ATTACHED. Yes No • • 15. Club Liquor License applicants answer the following (a) Is the applicant organization operated not for pecuniary gain? (b) Is the applicant organization a regularly operated solely for the object of a patriotic (c) How long has the club been incorporated? required) and attach: solely for a national, social, fraternal, patriotic, political or athletic purpose and chartered branch, lodge or chapter of a national organization which is or fraternal organization or society, but not for pecuniary gain? (d) Has applicant occupied an establishment for three years that was operated solely for the reasons stated above? Yes No • II ■ ■ ■ U (Three years 16. Brew -Pub License or Vintner Restaurant Applicants answer the following: (a) Has the applicant received or applied for a Federal Permit? (Copy of permit or application must be attached) Yes No IN • 17a. Name of Manager (for all on -premises applicants) application for a Hotel, Restaurant or Tavern License, 17b. Does this manager act as the manager of, or have licensed establishment in the State of Colorado? If (If this is an (DR 8404-I). Date of Birth the manager must also submit an Individual History Record a financial interest in, any other liquor yes, provide name, type of license and account number. Yes No IN ■ 18. Tax Distraint Information. Does the applicant or any other person listed on this application and including its partners, officers, directors, stockholders, members (LLC) or managing members (LLC) and any other persons with a 10% or greater financial interest in the applicant currently have an outstanding tax distraint issued to them by the Colorado Department of Revenue? If yes, provide an explanation and include copies of any payment agreements. Yes No ■ ■ DR 8404 (05/07/09) Page 4 19. If applicant is a corporation, partnership, association or limited liability company, applicant must list ALL OFFICERS, DIRECTORS, GENERAL PARTNERS, AND MANAGING MEMBERS. In addition applicant must list any stockholders, partners or members with OWNER- SHIP OF 10% OR MORE IN THE APPLICANT. ALL PERSONS LISTED BELOW must also attach form DR 8404 I (Individual History record), and submit finger print cards to their local licensing authority. NAME HOME ADDRESS, CITY & STATE DOB POSITION % OWNED' `fin cS. lacdvW(tx 232 Ef I za u Cr -A- v e! ow n t ()OA U Co 8Oa I *If total ownership percentage disclosed here does not total 100% applicant must check this box ❑ Applicant affirms that no individual other than these disclosed herein, owns 10% or more of the applicant Additional Documents to be submitted ❑ CORPORATION ❑ Cert. of lncorp. ❑ PARTNERSHIP ❑ Partnership ❑ LIMITED LIABILITY COMPANY ❑ ASSOCIATION OR OTHER Attach Agreement III copy by type of entity ❑ Cert. of Good Standing (if more than 2 yrs. old) ❑ Cert. of Auth. (if a foreign corp.) (General or Limited) ❑ Husband and Wife partnership (no written agreement) Articles of Organization ❑ Cert. of Authority (if foreign company) ❑ Operating Agrmt. of agreements creating association or relationship between the parties Registered Agent (if applicable) Address for Service I declare to the to co OATH OF APPLICANT under penalty of perjury in the second degree that this application and all attachments are true, correct, and complete best of my knowledge. I also acknowledge that it is my responsibility and the responsibility of my agents and employees I with the provisions of the Colorado Liquor or Beer Code which affect my license. Auth d Signature Title e (A)net' ,lIda)©I Date I 911 REPORT AND APPROVAL OF LOCAL LICENSING AUTHORITY (CITY/COUNTY) Date application filed with local authority Date of local authority hearing (for new license applicants; cannot be less than 30 days from date of application 12-47-311 (1)) C.R.S. THE LOCAL LICENSING AUTHORITY HEREBY AFFIRMS: Yes No That each person required to file DR 8404-I (Individual History Reco d) has: • Been fingerprinted • • • Been subject to background investigation, including NCIC/CCIC check for outstanding warrants • • That the local authority has conducted, or intends to conduct, an inspection of the proposed premises to ensure that the applicant is in compliance with, and aware of, liquor code provisions affecting their class of license • • (Check One) • Date of Inspection or Anticipated Date • Upon approval of state licensing authority. The foregoing application has been examined; and the premises, business to be conducted, and character of the applicant are satisfactory. We do report that such license, if granted, will meet the reasonable requirements of the neighborhood and the desires of the adult inhabitants, and will comply with the provisions of Title 12, Article 46 or 47, C.R.S. THEREFORE, THIS APPLICATION IS APPROVED. Local Licensing Authority for Weld County, Cobra tlq {� ..� Telephone Number 970-356-4000 x 4225 0 TOWN, CITY COUNTY Sig ure //iw �j�ny � ay County Commissioners Date MAR 28 2011 nature (attest) , ( ) .�� ` ,�;� fit,':',`,- itr - t7 :the the Board Board Date MAR 2 2011 doff- Mo'c STATE OF COLORADO John W. FflckMlooper, Governor Christopher E. Urbina, MD, MPH Executive Director and Chief Medical Officer Dedicated to protecting and improving the health and envkonment of the people of Colorado 4380 Cheny Creek Dr. S. Denver, Colorado 80248-1530 Phone (303) 692-2000 Located in Glendale, Colorado Ittplh ww.cdphe.state.00.us March 15, 2011 Laboratory SeMcae Divider 8100 Lowry Blvd. Denver. Colorado 80230.8928 (303) 692-3090 PWSID# CO -0262466 Ruben L Rodriguez, Registered Agent RJML, LLC d/b/a La Maravilla Restaurant/Lounge 232 Elizabeth Ct. Fort Lupton, CO 80621 Colorado Department ofPublic Health and Environment Certified Mail Number: 70051820 00003213 7320 RE: Service of Thinking Water Enforcement Order, Number: DT -110315-2 Dear Mr. Rodriguez: RJML, LLC is hereby issued the enclosed Enforcement Order (the "Order"). This Order is issued by the Colorado Department of Public Health and Environment, Water Quality Control Division (the "Department") pursuant to the authority given to the Department by §25-1.5-203 of the Colorado Revised Statutes ("C.R.S."). The Department haw's this Order upon findings that RJML, LLC has violated the Colorado Primary Drinking Water Regulations (the "Regulations") as described in the enclosed Order. As a recipient of an Order RJML, LLC may request a formal hearing to contest the Order in accordance with the Regulations, 5 CCR 1003-1, §1.6.7(g). Requests for such a hearing shall be filed in writing with the Department within thirty (30) calendar days after service of the Order. Such requests, at a minimum, shall contain the information specified in 5 CCR 1003-1, § 1.6.7(g), and 5CCR 1002-21, §21.4(B)(2). Hearings on Orders shall be held in accordance with applicable provisions of the State Administrative Procedure Act, Article 4 of Tide 24, C.R.S. and the procedural rules promulgated in 5 CCR 1002-21. This action could result in the imposition of further administrative or civil penalties. The Department or a State District Court is authorized pursuant to §25-1-114.1, C.R.S., to impose a penalty of up to $1,000 per violation per day. Please be advised that the Department is continuing its investigation into this matter and the Department may identify supplementary violations that warrant amendments to this Order or the issuance of additional enforcement actions. Ruben J. Rodriguez, Registered Agent RJML, LLC dlbda La ManrMa Restaurant/Lounge Orinidng Water - Enforcement Order Page 2 of t Should RJML, LLC desire to informally discuss this matter with the Department or if you have any questions regarding the Order, please don't hesitate to contact Lauren Worley at (303) 692- 3547 or by electronic mail at lauren.worley@state.co.us. Sincerely,. Aw3xJ-e. 576A - Russell Zigler, Legal Assistant Enforcement Unit Compliance Assurance Section WATER QUALITY CONTROL DIVISION Enclosure cc: Weld County Department of Public Health & Environment ec: Doug Cantrud, Engineering Section, CDPHE Dick Parachini, Watershed Program, CDPHE Lori Billeisen, Facility Operators Program, CDPHE Shawn McCaffrey, EPA Region VIII Nicole Grisham, Division of f Environmental Health and Sustainability, CDPHE Michael Beck, OPA Lauren Worley, Case Person, CDPHE COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT WATER QUALITY CONTROL DIVISION ENFORCEMENT ORDER & NUMBER: DT -110315-2 ADMINISTRATIVE PENALTY ASSESSMENT IN THE MATTER OF: RJML, LLC d/b/a: LA MARAVILLA RESTAURANT/LOUNGE PUBLIC WATER SYSTEM IDENTIFICATION NUMBER: CO -0262466 WELD COUNTY, COLORADO Pursuant to the authority vested in the Colorado Department of Public Health and Environment (the "Department") by §25-1-109 and §25-1.5-203 of the Colorado Revised Statutes ("C.R.S."), which authority is implemented through the Department's Water Quality Control Division (the "Division"), the Division hereby makes the following findings and issues the following Enforcement Order: GENERAL FINDINGS 1. RJML, LLC ("RJML") owns and/or operates a drinking water system, known as La Maravilla Restaurant/Lounge, located at 232 Elizabeth Court, Fort Lupton, Colorado, in Weld County, Colorado (the "System"). 2. RJML is a person as defined by 5 CCR 1003-1, §1.5.2(98). 3. RJML is a supplier of water within the meaning of §25-I.5-201(2), C.R.S. and its implementing regulation, 5 CCR 1003-1, §1.5.2(128). 4. The System is a public water system as defined by §25-1.5-201(1), C.R.S. and its implementing regulation, 5 CCR 1003-1, §1.5.2(107). 5. The Public Water System Identification Number ("PWSID") assigned to the System by the Division is PWSID #: CO -0262466. 6. Pursuant to 5 CCR 1003-1, §1.2, the System is subject to the Colorado Primary Drinking Water Regulations (the "Regulations"), which were adopted pursuant to §25-1.5-203, C.R.S. 7. The RJML provides piped water for human consumption from the System to at least twenty-five (25) people, but the System does not regularly serve at least twenty-five (25) of the same persons over six (6) sma,, uc Drinking Water—Enfinecmcnt Order and Administrative Penalty Page I of 13 months per year. The System is therefore classified as a "transient, non -community water system" as defined by 5 CCR 1003-1, §1.5.2(137). 8. The System's source of water is groundwater as defined by 5 CCR 1003-1, §1.5.2(63). 9. On June 5, 2009, the Weld County Department of Public Health & Environment ("Division Representative") conducted a compliance inspection of the System, pursuant to 5 CCR 1003-1, § 11.1(c), on behalf of the Division, pursuant to the Division's authority under §25-1.5-204, C.R.S., and 5 CCR 1003-1, §1.7, to determine the System's compliance with the Regulations. First Violation fFailure to Monitor and/or Report for Microbiological Contaminants) 10. Pursuant to 5 CCR 1003-1, §5.1.1(a), the System must collect total coliform samples at sites that are representative of water throughout the distribution system, according to a written sample -siting plan. 11. Pursuant to 5 CCR 1003-1, §5.1.1(e)(1), the System, which serves less than 1,000 persons, must monitor in each calendar quarter that the system provides water to the public. 12. Pursuant to 5 CCR 1003-1, §§1.6.4(a) and 5.1.1(b), the System is required to submit the results of all routine total coliform sampling and analyses to the Department for review within (a) the first ten (10) days following the month in which the result is received, or (b) the first ten (10) days following the end of the required monitoring period as stipulated by the Department, whichever of these is shorter. 13. Division records establish that the System failed to provide the Department with the results of its routine total coliform analyses for the following monitoring periods: Quarter Year Number of Samples Required Number of Samples Received 2nd Quarter 2010 1 0 3`d Quarter 2010 1 0 4u Quarter 2010 1 0 14. RJML' s failure to submit the results of the System's routine total coliform analyses to the Department constitutes violation(s) of 5 CCR 1003-1, §§1.6.4(a) and 5.1.1(b). Additionally, if RJML failed to perform routine total coliform monitoring during the identified periods, such failure to perform the monitoring constitutes violation(s) of 5 CCR 1003-1, §5.1.1(e)(1). Second Violation (Failure to Measure/Report Residual Disinfection Concentration) RJML LLC Drinking Water— Enforcement Order and Administrative Penalty Paget of 13 15. Pursuant to 5 CCR 1003-1, §13.2(a)(1), a groundwater source must be disinfected at all times that it is used to serve water to the public. The groundwater system must use disinfection methods that are approved by the Department. Groundwater source disinfection methods may include physical treatment methods but must include at least one chemical treatment method. 16. Pursuant to 5 CCR 1003-1, § 13.2(a)(2), the groundwater system must maintain a residual disinfectant concentration whenever serving water from a groundwater source to the public. 17. Pursuant to 5 CCR 1003-1, § 13.2(b)(2), the residual disinfectant concentration in the distribution system must be measured at least at the same points and at the same time as total coliforms are sampled. The System must monitor for total colifoun in each calendar quarter that the System provides water to the public pursuant to 5 CCR 1003-1, §5.1.1(e)(1). 18. Pursuant to 5 CCR 1003-1, §§13.6(a)(2) and I.6.4(a), the System shall report to the state the results of any test measurement or analysis required by the Colorado Primary Drinking Water Regulations within (1) the first ten calendar days following the month in which the result is received, or (2) the first ten calendar days following the end of the required monitoring period, as stipulated by the Department, whichever of these is shorter. 19. Review of bacteriological sampling results submitted to the Division establishes that the System did not measure and/or report its residual disinfection concentration in the 2°°, 3m and 4th quarters of calendar year 2010. 20. RJML's failure to report for residual disinfectant concentrations in the distribution system constitutes violation(s) of 5 CCR 1003-1, §§ 13.6(ax2) and 1.6.4(a). Furthermore, if RJML failed to measure the residual disinfectant concentration in the distribution system, such failure constitutes violations of 5 CCR 1003-1, §13.2(b)(2). Third Violation (Failure to Obtain Plans and Specifications Approval Prior to Construction. Improvements or Modificationsi 21. Pursuant to 5 CCR 1003-1, §1.11.2(b), no person shall commence construction of any new waterworks, or make improvements to or modify the treatment process of an existing waterworks, or initiate use of a new source, until plans and specifications for such construction, improvements, modifications or use have been submitted to, and approved by the Department. The Department shall grant such approval when it finds that the proposed facilities are capable of complying, on a continuous basis, with design criteria as stated above, and with all applicable laws, standards, rules and regulations. 22. During the June 5, 2009, compliance inspection of the System, the Division Representative observed that RJML had constructed and installed a reverse osmosis system without submitting plans and specifications for the treatment equipment design to the Department. KJM, LLC Drinking Water —Enforcement Order and Administrative Penalty Page 3 of 13 23. In an inspection follow-up letter, dated June 5, 2009, addressed to RJML, the Division Representative advised RJML of the requirement for the plans and specifications approval for the System and requested that RJML provide a written response addressing the failure to submit plans and specifications for the System improvements for reverse osmosis treatment. 24. Division records to -date establish that the System did not respond to the Division Representative's June 5, 2009, letter and did not submit plans and specifications for the System improvements for Department approval. 25. Division records establish that RJML has not received plans and specifications approval from the Department for the System's reverse osmosis treatment. 26. RJML's failure to submit and/or obtain Department approval o£ the System's plans and specifications prior to construction, improvements or modifications to the System constitutes violation(s) of 5 CCR 1003-1, §1.11.2(b). Fourth Violation (Failure to Prepare a Written Microbiological Contaminants Sample-Sitina Plan) 27. Pursuant to 5 CCR 10034, §5.1.1(a), the System must collect total colifonn samples at sites which are representative of water throughout the distribution system according to a written sample -siting plan. 28. During the June 5, 2009, compliance inspection of the System, the Division Representative determined that the System lacked a properly designed bacteriological sampling plan pursuant to 5 CCR 1003-1, §5.1.1(a). 29. In a letter reporting the results of the compliance inspection, dated June 5, 2009, addressed to RJML, the Division Representative advised RJML of the requirement for the written microbiological contaminants sample -siting plan and requested that RJML respond in writing to the Division Representative by July 20, 2009, with an outline of the course of action that will be taken and the date by which the System will brought into compliance with the written microbiological contaminants sample -siting plan requirement. 30. Pursuant to 5 CCR 1003-1, §1.12.1(e), each monitoring plan prepared by the System must contain Individual Rule Sampling Plans. 31. Division records to date establish that the System did not respond in writing to the Division Representative's June 5, 20009, letter and RJML has not prepared an adequate written microbiological contaminants sample -siting plan. 32. RJML's failure to develop a written microbiological contaminants sample -siting plan for the System constitutes violation(s) of 5 CCR 1003-1, §5.1.1(a). RAIL, LLC Drinking water— Enfercemeat Oilier and Administrative Penally paged of 13 Fifth Violation (Failure to Develop/Submit a Monitorine Plan) 33. Pursuant to 5 CCR 1003-I, §1.12, each public water system shall develop and implement amonitoring plan. The public water system shall maintain the plan and make it available for inspection by the Department. 34. Pursuant to 5 CCR 1003-1, §1.12.2(a)(4), the System was required to submit a monitoring plan to the Department by April10, 2006. 35. Pursuant to 5 CCR 1003-1, §1.12.1(e), each monitoring plan prepared by the System must contain Individual Rule Sampling Plans. Each sampling plan shall meet all requirements of the respective provision, including: (1) Frequency and approximate time of collection; (2) Sample site location identification and associated identification number; (3) If appropriate, justification for the site selection; (4) Sample preservation, quality assurance, and quality control procedures, including procedures for equipment calibration; (5) Analysis procedure (certified laboratory or on -site by a party approved by the Department); (6) Monitoring results presentation format; (7) Procedures to accacs and report compliance status for MCLs, ALs, MRDLs, TTs and, if applicable, disinfection byproduct precursor removal efficiency; (8) The rationale used by the system to identify the sampling locations selected to represent the distribution system, and (9) A process to review and update the selected distribution system sampling locations to account for changes due to growth or other significant changes to the distribution system. 36. During the June 5, 2009, compliance inspection of the System, the Division Representative determined that the System lacked a monitoring plan detailing the System's background information, sources, treatment and distribution system. 37. In a letter reporting the results of the compliance inspection, dated June 5, 2009, addressed to RJML, the Division Representative requested that RJML provide a written response addressing the inspection identified deficiencies by July 20, 2009. 38. Division records establish that RJML has neither developed nor submitted the required monitoring plan to the Division. 39. RJML's failure to develop a monitoring plan for the System constitutes a violation of 5 CCR 1003-1, §1.12. If RJML subsequently developed its monitoring plan, but failed to submit a copy of the monitoring plan for the System to the Division, such failure constitutes a violation of 5 CCR 1003-1, § 1.12(a)(4). Sixth Violation (Failure to Implement a Cross -Connection Control Protrami 40. Pursuant to 5 CCR 1003-1, § 12.1, a public water system shall control hazardous cross -connections and protect the public water system from contamination by implementing a cross -connection control program in the following manner: amp uc Drinking Water— Enforcement Order and Administrative Penalty Page S.of 13 a. Identifying potentially uncontrolled hazardous service cross -connections. b. Requiring system users to install and maintain containment devices on any uncontrolled hazardous service cross connections, provided the Department has determined that the device is consistent with the degree of hazard posed by the uncontrolled cross connection. c. Installation of containment devices shall be approved by the public water system upon installation. d. All containment devices shall be tested and maintained as necessary on installation and at least annually thereafter, by a Certified Cross -Connection Control Technician. In addition, pursuant to 5 CCR 1003-1, § 12.1(c), each public water system shall retain maintenance records for three years for all containment devices and these records shall be available for Department inspection. 41. During the June 5, 2009, compliance inspection of the System, the Division Representative noted that the System did not have a written Cross -Connection Control Program. 42. In a letter reporting the results of the compliance inspection, dated June 5, 2009, addressed to RJML, the Division Representative advised RJML of the requirement for the System to implement a cross - connection control program and requested that RJML respond in writing to the Division Representative by July 20, 2009, with an outline of the course of action that will be taken and the date by which the System will be brought into compliance with the cross -connection control program requirement. 43. Department records to date establish that the System has failed to provide the Department with any information demonstrating that the System has implemented a cross -connection control program. 44. RJML's failure to implement a cross -connection control program for the System constitutes violation(s) of5 CCR 1003-1, §12.1. Seventh Violation (Failure to Retain System Records) 45. Pursuant to 5 CCR 1003-1, § 1.6.3, each supplier shall retain on its premises or at a convenient location near its premises the following records: i. Records of microbiological analyses and turbidity analyses made pursuant to Articles 5 and 7 of the Colorado Primary Drinking Water Regulations, for not less than five (5) years. Records of chemical analyses for not less than ten (10) years. The actual laboratory reports may be kept, or data may be transferred to tabular summaries, provided that the following information is included: (1) The date, place, and time or sampling, and the name of the person who collected the sample; a3M1 LLC Driniss Wain- Enfmcanent Order and Administrative Penalty Page 6 of 13 (2) Identification of the sample as to whether it was a routine distribution system sample, routine entry -point -to -the -distribution sample (EPTDS), confirmation sample, raw or processed water sample or a special purpose sample; (3) Date of analysis; (4) Laboratory and person responsible for performing analysis; (5) The analytical technique/method used, and (6) The results of the analyses. ii. For each violation of the Colorado Primary Drinking Water Regulations, the records of action taken by the public water system to correct the violation shall be kept for not less than three (3) years after the date on which the last action was taken with respect to the particular violation involved. iii. Copies of any written reports, summaries or communications relating to sanitary surveys of the system conducted by the system itself, a private consultant, or a local, state or federal agency shall be kept for not less than ten (10) years after completion of the sanitary survey. iv. Records concerning a variance or exemption granted to the system shall be kept for not less than five (5) years following the expiration of such variance or exemption. v. Copies of public notices and consumer confidence reports issued pursuant to Article 9 and certifications made to the Department must be kept for not less than three (3) years after issuance. vi. All records pertaining to the operation and water quality of a public water system are public information and shall be made available to the public by the Department, at request, during normal working hours. vii. Upon request of the Department the public water system shall submit copies of any records required to be maintained for public notification or copies of any documents in existence, which the Department is entitled to inspect pursuant to the authority of the Colorado Primary Drinking Water Regulations. 46. During the June 5, 2009, compliance inspection of the System, the Division Representative determined that written records or log sheets to indicate that the operator in charge, or that a delegated person, is making the appropriate adjustments to chemical feeding equipment to ensure its operation dating back to December 9, 2008, were not available on the site for review. 47. In a letter reporting the results of the compliance inspection, dated June 5, 2009, and addressed to RJML, the Division Representative advised RJML of the requirement for the System to make System monitoring records available for review requested RJML to respond in writing to the Division Representative by July 20, 2009, with an outline of the course of action that will be taken and the date by which the System will brought into compliance with the record keeping requirements. ttmu., LLC Drinking Wrier— Enforcement Order and Administrative Penalty Page 7 of 13 48. Department records to date establish that the System failed to provide the Department with any information indicating the action taken to address the System's record keeping deficiencies. 49. RJML's failure to retain System records on the premises, or at a convenient location near its premises, constitutes violation(s) of 5 CCR 1003-1, § 1.6.3. COMPLIANCE REQUIREMENTS Based upon the foregoing factual and legal determinations and pursuant to 5 CCR 1003-1, §1.6.7, RJML is hereby ordered to: 50. Immediately comply with the Colorado Primary Drinking Water Regulations, 5 CCR 1003-1, Articles 1 through 13. Further, the Division hereby orders RJML to comply with the following specific terms and conditions of this Enforcement Order. 51. Immediately take steps to comply with the microbiological contaminant and residual disinfectant concentration monitoring/reporting obligations as required by 5 CCR 1003-1, Articles 5 and 13. 52. Within thirty (30) calendar days after receipt of this Order, RJML shall submit the results of any microbiological contaminant (total coliform) and residual disinfectant concentration monitoring performed for the second, third and fourth quarters of 2010. 53. If the second, third and fourth quarter 2010 total colifomi and residual disinfectant concentration sampling has not been conducted by the System, RJML shall collect a total coliform sample from the distribution system, and/or at the entry point to the distribution system, according to the System's written sample -siting plan within 20 calendar days of receipt of this Order. The total coliform and residual disinfectant concentration samples must be collected properly and analyzed by a Department certified laboratory in accordance with approved methods. RJML shall provide the Department with the results of the total coliform and residual disinfectant concentration analyses within ten (10) calendar days of receipt of the results from the laboratory. 54. Within sixty (60) calendar days after receipt of this Order, RJML shall develop and provide a written records retention policy or procedure outlining how the System will retain System records on the premises, or at a convenient location near its premises, in accordance with 5 CCR 1003-1, §1.6.3. 55. Within thirty (30) calendar days from the date of this Order, RJML shall develop, implement and submit to the Division a monitoring plan pursuant to 5 CCR 1003-1, §1.12, which includes an individual rule sampling plan/microbiological contaminant sample -siting plan, 5 CCR 1003-1, §§1.12.1(e) and 5.1.1(a), to reflect the System's current configuration, treatment and operation. The plan shall specifically outline how RJML will ensure that samples collected are representative of water quality throughout the distribution system(s), that samples should be taken both with temporal and spatial separation to ensure RJML, LLC Drinking Water —Enforcement Order and Amniiielntive Peaty Page g of 13 representative samples are obtained of water quality throughout the distribution system and throughout the month of service and that samples are not to be taken all on the same day. A guidance document on how to prepare a monitoring plancan be viewed at the following internet location: http://www. cdphe.state. co. us/wq/drinkingwater/pdf/MonitoringPlanTemplate.pdf A guidance document on how to prepare a small system microbiological rule sampling plan can be viewed at the following internet location: htlp://www.cdphe.state.co.us/wq/drinkingwater/pdf/BulletinO2_01BactSamplingPlanguidanceDoc.pdf 56. Within thirty (30) calendar days after receipt of this Order, RJML shall provide a written description of how the System's Cross -Connection Control Program is being implemented. A Sample Cross -Connection Control Program for Small Systems guidance document can be viewed at the following internee location: hap://www.cdphe.state.co.usewg/drinkingwater/pdfl'cross_connection co itroLPdf 57. Within sixty (60) calendar days after receipt of this Order, RJML shall submit for Department review and approval, plans and specifications for the System's recently constructed reverse osmosis system. Upon review of the submitted plans and specifications, if the Department determines that the implemented system improvements are deficient, RJML shall within sixty (60) calendar days of the Department's notice certify in writing that the deficiencies have been corrected, as necessary, and that the System is now constructed in accordance with the Department approved design plans, specifications and the Regulations. The Division's application for Construction Approval can be found at the following internet location: http:I/www.cdphe.state.co.us/wq/drinkingwater/pdf/CapacityDevelopment/Attachment2 NewSyste m_Capacity.pdf 58. Within thirty (30) calendar days after receipt of this Order, if it has not already done so, RJML shall issue a public notice in accordance with 5 CCR 1003-1, §9.2 for each violation identified in this Order. Within ten (10) calendar days of completion of each required public notification, RJML shall submit to the Division, along with the mandatory certification, a representative copy of each typeof notice distributed, published, posted, and/or made available to the persons served by the system and/or to the media. Additional guidance for proper public notification can be viewed at the following Internet location: http://www.cdphe.state.co.us/wq/drinkingwater/pdf/PublicNotice/PN Guidance Mar2003.pdf RJML, LW Drinking Water —Enforcement Order and Administrative Penalty Page 9 of 13 ORDER FOR ADMINISTRATIVE PENALTY 59. Pursuant to §25-1-114.1(2.5Xa), C.R.S. any person who violates the Colorado Primary Drinking Water Regulations or any final Enforcement Order issued by the Department, shall be subject to an administrative penalty as follows: a. For systems that serve a population of more than ten thousand people, an amount not to exceed one thousand dollars per violation per day; or b. For systems that serve a population of ten thousand people or less, an amount not to exceed one thousand dollars per violation per day, but only in an amount, as determined by the Division, that is necessary to ensure compliance. 60. Based upon the facts described in this action the Department has determined that an administrative penalty is appropriate in this matter and therefore assesses an administrative penalty of six -hundred and sixty dollars ($660.00) for the specific violations identified in this action. The reasoning behind this penalty amount is detailed in the administrative penalty methodology/calculation worksheet, which is incorporated herein by reference and enclosed as Exhibit A. Terms of Administrative Penalty Payment 61. If RJML does not contest the findings and penalty assessment set out above, payment of the administrative penalty for the violations shall be forwarded to the Colorado Department of Public Health and Environment within sixty (60) calendar days of the date of issue of this action. Method of payment shall be by certified or cashier's check drawn to the order of the "Colorado Department of Public Health and Environment," and delivered to: Colorado Department of Public Health and Environment Water Quality Control Division I WQCD-B2-CAS Compliance Assurance Section Attention: Lauren Worley 4300 Cherry Creek Drive South Denver, Colorado 80246-1530 (To facilitate payment processing, please ensure that Ms. Worley's name is on the outside of the envelope). 62. Payment or appeal of the administrative penalty in this manner does not relieve RJML of its obligation to perform the activities required by this enforcement action. RJML, LW Drinking Was Eaforoemad Order and Administrative Penalty Page 10 of 13 NOTICES AND SUBMITTALS 63. For all documents, plans, records, reports and replies required to be submitted by this order, RJML shall submit an original and one copy (electronic is preferred) to the Division at the following address: Colorado Department of Public Health and Environment Water Quality Control Division / WQCD-82-CAS Compliance Assurance Section Attention: Lauren Worley 4300 Cherry Creek Drive South Denver, Colorado 80246-1530 Email: lauren.worley@state.co.us Fax: (303) 782-0390 (For any facsimile transmittals, please include a cover sheet addressed to Ms. Worley). 64. All reports, notices, summaries, and certifications required to be submitted to the Division by the public water system must bear the original signature of the owner or the owner's authorized representative. NOTICE OF COMPLETION 65. RJML shall submit a Notice of Completion to the Division upon satisfactory completion of all requirements of this Enforcement Order. The Division shall either accept or reject the Notice of Completion in writing. If the Division rejects the Notice of Completion, it shall include in its notice a statement identifying the requirements that the Division considers incomplete or not satisfactorily performed and a schedule for completion. If RJML wishes to dispute the Division's rejection of its Notice of Completion, it shall, within fifteen (15) calendar days of receipt of the Division's rejection, submit a written statement as to its belief of full compliance, addressing in detail all concerns the Division raised in the rejection letter to the System's Notice of Completion. PRIOR APPROVAL REOUIREI) 66. Pursuant to 5 CCR 1003-1, §1.11.2, no person shall commence construction of any new waterworks, or make improvements to or modify the treatment process of an existing waterworks, or initiate use of a new source, until plans and specifications for such construction, improvements, modifications or use have been submitted to, and approved by the Department. The Department shall grant such approval when it finds that the proposed facilities are capable of complying, on a continuous basis, with all applicable laws, standards, rules and regulations. RAIL. LLC Drinking Water— Enforcement Order and Administrative Penalty Page l l of 13 POTENTIAL ADMINISTRATIVE/CIVIL AND CRIMINAL PENALTIES 67. You are also advised, pursuant to §25-1-114(4), C.R.S., any person, association, or corporation, or the officers thereof, who violates, disobeys, or disregards any provision of the Regulations or an Enforcement Order is guilty of a misdemeanor and, upon conviction thereof, shall be punished by a fine of not more than one thousand dollars ($1,000), or by imprisonment in the county jail for not more than one (1) year, or by both such fine and imprisonment and, in addition to such fine and imprisonment, shall be liable for any expense incurred by health authorities in removing any nuisance, source of filth, or cause of sickness. In the event that RJML does not achieve complete and timely compliance with all of the terms and conditions outlined herein, including full and timely payment of administrative penalties, the Department reserves, in addition to any other remedies allowed by law, its right under §25-1-114(4), C.R.S., to pursue an action for additional penalties. REQUEST FOR HEARING OR APPEAL 68. You are further advised, pursuant to 5 CCR 1003-1, §1.6.7(g), that a recipient of an Enforcement Order may request a hearing contesting such order. Requests for such a hearing shall be filed in writing with the Department within thirty (30) calendar days alter service of the order. Such requests, at a minimum, shall contain the information specified in 5 CCR 1003-1, §1.6.7(g) and 5 CCR 1002-21, §21.4(B)(2). Hearings on Enforcement Orders shall be held in accordance with applicable provisions of the State Administrative Procedure Act, Article 4 of Tide 24, C.R.S. and the procedural rules promulgated in 5 CCR 1002-21. 69. Pursuant to §25-1-114.1(2.5)(b) C.R.S. an Administrative Penalty Assessment may be appealed to the Water Quality Control Commission. Requests for such an appeal should be filed in writing with the Water Quality Control Commission within thirty (30) calendar days after service of the penalty assessment. Such requests, at a minimum, shall contain the information specified in 5 CCR 1002-21, §21.4(B)(2). Hearings on Administrative Penalty Assessments shall be held in accordance with applicable provisions of the State Administrative Procedure Act, Article 4 of Title 24, C.R.S. and the procedural rules promulgated in 5 CCR 1002-21. ADDITIONAL ACTION 70. You are further advised that under §25-1-114.1(1), C.R.S., the Department may institute a civil action against any person who violates a final Enforcement Order of the Department issued for violation of any minimum general sanitary standard or regulation adopted pursuant to §25-1.5-203, C.R.S. 71. Additionally, the Department may request the Attorney General to seek a temporary restraining order or permanent injunction to prevent or abate any violation of a minimum general sanitary standard or regulation adopted pursuant to §25-1.5-203, C.R.S. Further information concerning the aforementioned action is contained in §25-1-114.1(3), C.R.S. wna, uc Drinking Water— Enforcement Osier and Administrative Penalty Page 12 of 13 Issued at Denver, Colorado, this �5%day of Protr04 , 2011. FOR THE COLORADO DEPARTMENT OF PUBLIC HEALTH ANA ENVIRONMENT )22 Lori M. Gerzina, Section manager Compliance Assurance Section Water Quality Control Division RJM L, LW Thinking Water — Enfofcement Order and Administrative Penalty Page 13 of 13 5xh167tA RJML, LLC d/b/a LA MARAVILLA RESTAURANT/LOUNGE PUBLIC WATER SYSTEM IDENTIFICATION NUMBER: CO -0262466 WELD COUNTY, COLORADO ADMINIS 11tATIVE PENALTY COMPUTATION WORKSHEET (March 15, 2011) Penalty Summary Penalty Calculation -Violation Number 1 5360.00 Violation: Failure to Monitor and/or Report for Microbiological Contaminants Regulation Violated: 5 CCR 1003-1, §§1.6.4(a), 5.1.1(b) and (ex1) Penalty Cakulation -Violation Number 2 $300.00 Violation: Failure to Measure/Report Residual Disinfection Concentration Regulation Violated: 5 CCR 1003-1, §§1.6.4(a), 13.2(a)(2) and (bX2) TOTAL PENALTY S660.00 wrn LLC Administrative Penalty Computation Worlduet Page l of l Exhibit A ADMINISTRATIVE PENALTY COMPUTATION WORKSHEET VIOLATION NUMBER: 1 I *stn® Name: La Matravila Reataurant/L0uu eI PWSID Number. CO -0262466 Date of Enforeergent Order!. Marelv15; 2Qi 1 I Nutiiberi DCG1103154 RcgolattonYiolated: Farutt etoMoi itor'andlorReport for Microbiological Contaminants, 5 CCR 10034, 5.1.10) and (o)al) Population Served; -125 Part I — Base Penalty Calculation Ltwla[ion Type ` Population -Range. Amount,in, Dollars Line 1 Failure to Monitor and/or Report for Microbiological Contaminants, 5 CCR 1003-1, §§1.6.4(a), 5.1.1(b) and (e)(1) < 500 Served $60.00 Part H — Anulication of Aeeravatine or Mitieatine Factors ,Aggravating / Mitigating Factors °r Babe Penalty Increase' or Increase Amount in Dollars Line 2 Factor A: Threat to Public Health and Welfare $0.00 Justification: n/a Line 3 Factor B: Intentional, Reckless, or Negligent Actions $0.00 Justification: n/a Line 4 Factor C: Recalcitrance or Recidivism $0.00 Justification: n/a Line 5 Factor I): Voluntary and Complete Disclosure of Violations $0.00 Justification: n/a Line 6 Factor E: Full and Prompt Cooperation $0.00 Justification: n/a Line 7 Factor F: Environmental Compliance Program j $0.00 Justification: n/a Line 8 Factor G: Other Aggravating or Mitigating Circumstances $0.00 Justification: n/a Line 9 Sum of Lines 2 through Line 8 $0.00 Line 10 Adjusted Base Penalty (sum of Line t + Line 9) $60.00 a Mc Administrative Penalty Computation Worksheet Page 2of2 ExhibitA Part III — Determination of Days of Violation Days of Violation Line 11 3 Total Days of Violation Justification: The Division has chosen to consider the 2"" 3'd and 4° Quarter 2010 failure to monitor and/or report for microbiological contaminant violations as a single day violations respectively. Part IV — Determination of Multi -Day Penalty Amongst Amouut:in Dollars Line 12 Multi -Day Penalty Amount Calculations: Total Days of Violation (3) x ($60.00) = $180.00 Part V — Economic Benefit Consideration 5180.00 Amount in. Doll t. Line 13 Economic Benefit: Justification: The Division believes that the System realized an economic benefit by failing to monitor since it has avoided its cost for the tests itself as well as the cost of the labor involved in obtaining sample bottles, conducting the testing, and transporting the samples to a lab. Calculations: Laboratory Cost for Analysis of Microbiological Contaminants ($20.00) x (3) = $60.00 Sampling and Handling Costs (40.00) x (3) _ $120.00 $180.00 Part VI — Violation Penalty Total Amount in Dollars Line 14 Total Administrative Penalty: (Line 12 + Line 13) Part VII — Ability to Pay Adjustment $360.00 Amount in Dollars Line 15 1 $0.00 Ability to Pay Reduction: Justification: Not Applicable. The Division does not have any documented information suggesting that the R)ML, LLC has an inability to pay the assessed penalty amount. Part VIII — Final Adjusted Penalty Amount in Dollars Line 16 Total Administrative Penalty: SLine 14 - Line 15) tuba, LW Administrative Penalty Computation Worksheet Page 3 of 3 $360.00 tikitA ADMINISTRATIVE PENALTY COMPUTATION WORKSHEET VIOLATION NUMBER: 2 System Name: IA Marrvilla Reafauaant/Luuage I PWSID Number: C(1`0262466 Date, of Enforcement Order: March 15, 2011 Number:. DC -110315-2 Regulation Violated: Failure fcsMane/Report Residual Disinfection Concentration, 5 CCR 1003-1, §§1.6.4(a),13.2(a)(2) and tb)(2) Population Served: 125; Part I — Base Penalty Calculation Violation Type Population Range ^ Amount is Dollars Line I Failure to Measure/Report Residual Disinfection Concentration < 500 Served $30.00 Part II — Application of A>rsrravatinn or Mitiieatine Factors Aggravating/Mitigating Fatten % Dane ° Increase or Deereiise, onnt;in DSO $0.00 Line 2 Factor A: Threat to Public Health and Welfare _ Justification: n/a Line 3 Factor B: Intentional, Reckless, or Negligent Actions $U .00 Justification: n/a Line 4 Factor C: Recalcitrance or Recidivism $0.00 Justification: n/a Line 5 Factor D: Voluntary and Complete Disclosure of Violations $0.00 Justification: n/a Line 6 Factor E: Full and Prompt Cooperation I $0.00 Justification: n/a Line 7 Factor F: Environmental Compliance Program I { $0.00 Justification: n/a Line 8 Factor G: Other Aggravating or Mitigating Circumstances $0.00 Justification: n/a Line 9 Sum of Lines 2 through Line S $0.00 Line 10 Adjusted Base Penalty (Sam of Line r+Line 9) S30.00 wan [I.C Administrative Penalty Computation Worksheet Page 4 of 4 ExhibitA Part III — Determination of Days of Violation Days of Violation. Line 11 Total Days of Violation Justification: The Division has chosen to consider the 2m, 3'" and 4d' Quarter 2010 failure to measure/report residual disinfection concentration violations as single day violations respectively. 3 Part IV — Determination of Multi -Day Penalty Amount Amount in Dollars Line 12 Multi -Day Penalty Amount I $90.00 Calculations: Total Days of Violation (3) x (130.00) = 390.00 Part V — Economic Benefit Consideration Amount in Dollarp. Line 13 Economic Benefit Justification: The Division believes that the System realized an economic benefit by failing to monitor since it has delayed its cost for the tests itself as well as the cost of the labor involved in obtaining sample bottles, conducting the testing, and transporting the samples to a lab. Calculations: Laboratory Cost for Analysis of Chlorine ($30.00) x (3) = 390.00 Sampling and Handling Costs (40.00) x (3) = $120.00 3210.00 Part VI — Violation Penalty Total Amonnt.in Dollars Line 14 Total Administrative Penalty: (Line 12 + Line 13) $300.00 Part VII — Ability toYay Adjustment Amount in Dollars Line 15 Ability to Pay Redaction: Justification: Not Applicable. The Division does not have any information suggesting that the RIML, LLC has an inability to pay the assessed penalty amount. $0.00 Part VIII — Final Adjusted Penalty Amount in Dollars Line 16 Total Administrative Penalty; (Line 14 - Line 15) RJMI, tic Administrative Penalty Computation Worksheet Page 5015 $300.00 STATE OF COLORADO Bill Ritter, Jr., Governor Martha E. Rudolph, Executive Director Dedicated to protecting and improving the health and environment of the people of Colorado 4300 Cherry Creek Dr. S. Denver, Colorado 80246-1530 Phone (303) 692-2000 TDD Line (303) 691-7700 Located in Glendale, Colorado http://www.cdphe.state.co.us August 18, 2010 Ruben Rodriguez La Maravilla Lounge 232 Elizabeth Court Ft. Lupton, CO 80621 Laboratory Services Division 8100 Lowry Blvd. Denver, Colorado 80230-6928 (303) 692-3090 RE: Revocation of the Provisional Drinking Water 20 mg/1 Nitrate MCL La Maravilla Lounge, PWSID CO0262466, Weld County Dear Mr. Rodriquez Colorado Department of Public Health and Environment On April 14, 2006, the Water Quality Control Division (the "Division") determined that La Maravilla Lounge (the "system") was eligible for a provisional drinking water nitrate maximum contaminant level (MCL) of 20 mg/L as allowed by Section 6.1.1(c) of the Colorado Primary Drinking Water Regulations (CPDWR). This provisional approval was dependent upon the system satisfactorily demonstrating to the Division that: 1. Such water will not be available to children under six (6) months of age; and 2. The non -community water system is meeting the public notification requirement under section 9.2.2, including continuous posting of the fact that nitrate levels exceed 10 mg/L and the potential health effects of exposure; and 3. Local and State public health authorities will be notified annually of nitrate levels that exceed 10 mg/L; and 4. No adverse health effects shall result." It is the opinion of the Division that given the current use of La Maravilla Lounge, it is not feasible to insure water is not made available to children under six (6) months of age. Effective immediately, La Maravilla Lounge is subject to section 6.1.5 of the CPDWR; which La Maravilla Lounge August 18, 2010 Page 2 of 2 states that all public water systems are subject to the nitrate maximum contaminant level (MCL) of 10 milligrams per liter (mg/L). Compliance with the nitrate MCL is determined based on an average of the concentrations exhibited by an original sample and a confirmation sample, if the original sample exhibits a nitrate concentration above the MCL. Additionally, La Maravilla Lounge will remain on a quarterly nitrate sampling schedule until such time that the system can demonstrate that the nitrate levels are reliably and consistently below 10 mg/l. If at any time the nitrate level exceeds 10 mg/L during your routine monitoring, the system will be required to obtain a confirmation sample within 24 hours of receiving the results. If the average of the routine and confirmation samples exceed 10 mg/L, the public water system will be in violation of section 6.1.5 of the CPDWR and may be required to install nitrate treatment. . If you have questions, please contact me at (303) 692-3527 or by electronic mail at bryan.picklena,state.co.us. Sincerely, Bryan Pickle Transient Groundwater Compliance Specialist Drinking Water Compliance Assurance Unit Water Quality Control Division cc: Drinking Water File, CO262466 Weld County Department of Public Health & Environment ec: Bret Icenogle, Engineering Unit Manager, WQCD-CDPHE Rick Koplitz, Drinking Water Compliance Unit Manager, WQCD-CDPHE Doug Camrud, District Engineer, WQCD-CDPHE (its 1 COLORADO MEMORANDUM To: Christie Peters, Deputy Clerk to the Board February 25, 2011 From: Bethany Salzman, Zoning Compliance Officer, Dept. of Planning Services Subject: LC0044 Review of the following liquor license application by the Department of Planning Services shows the following: 40-48501-0000 RJML, LLC dba La Maravilla 13015 Weld County Road 16 Fort Lupton, Colorado 80621 Zone District: C-3 (through Z-66) This use is allowed through the zone district and a Site Plan Review (SPR-341) permit. Please be advised that the current Site Plan Review is for the operation of a ANightclub / Restaurant@. Any deviation from their existing permit or plans would require an amendment. As a result of researching my computer and files, there are no current violations occurring on the property. SERVICE, TEAMWORK, INTEGRITY, QUALITY LIQUOR/BEER RENEWAL REVIEW FORM Date: February 22, 2011 TO: DEPUTY Lisa Carpenter FROM: Clerk to the Board SUBJECT: Liquor License Check In accordance with the new procedure for Liquor and/or beer license checks, please review all records on the following establishment for any associated reports during the last year and return your report to the Weld County Clerk to the Board's Office within two weeks. Your report will be used by the Board of County Commissioners in considering renewal of the liquor and/or beer license. PLEASE RESPOND NO LATER THAN: MARCH 9, 2011 ESTABLISHMENT: RJML, LLC DBA LA MARAVILLA 13015 WELD COUNTY ROAD 16 FORT LUPTON, CO 80621 Current license expires: MARCH 10, 2011 *******************************************************************************************************• No concerns Deputy's Initials The Sheriffs Office had a concern and the deputy has mutually worked with the licensee to correct the concern. (Complete Attached Worksheet) Unresolved concerns exist requiring a Probable Cause Hearing scheduled by the Board of County Commissioners. (Complete Attached Worksheet) ******************************************************************************************************** Please notify L_41'° f E rc E C at Extension Zn - 33.-u, of the date and time of the Board of Commissioner's renewal hearing. Liquor/Beer License Worksheet The following concerns are noted: Hone The Licensee and the Sheriffs Office have collectively agreed to implement the following to correct concerns noted above: (A time line and corrective action should be listed for each concern) hQY1P_ 4,k Es -5- Qf 3/7/1/ ent Owners Please Print Date Estab hm nt Signature D puty's Signature Use another sheet of paper or attach separate proposal to this packet if needed. Attach copies of all reports associated with this establishment for the last year. Both the Deputy and the Owner of the establishment will be required to attend the Liquor Hearing to testify to the above agreement. WELD COUNTY S_HERIFF'S OFFICE Community Resource Office LIQUOR ENFORCEMENT WORKSHEET 1950 0 Street Greeley, Colorado 80631 Voice (970) 356-4015 • Fax (970) 304-6467 Inspection Report G Incident Report CF : Ixer�c1rrvleNart�r�c 1 / I� 1 �L = Licensee Name , Lice # J Type: r201 C' -- D3 )404€1 �:�4` Date of Report l Incident3 71 i Address. 3 5 (] I E1 S � SI(G` ilSr.301� Person Contacted: EJ u \- 4 City, Slate, Zip r} L l J C o t6 (F, l ` Telephone #: 7� G� _ � C� - q. Yes No NIA State • r License Posted State Sales Tax License Posted County Liquor License Posted Federal Form 11 ' Call 800) 3.98-2822 Food Service License Posted Minor Warning Sign Posted Meals and Snacks Available Cleanliness Adequate _ Books & Invoices Available Alcohol Beverage Stock Acceptable [Warning Vrrrlatron Subject. Clothing: Address: u7Foilow-Up inspection I Don Ma-!erRegistered License in Control of Premises Trade Name Property Registered Premises Physical Control Adequate Acceptable Dispensing System Off Premise Storage Licensed Only Permitted Items Sold Alcohol From Permitted Source Sales of Liquor to Minors Sales to Intoxicated Persons / Representative Signature I Date: 1 Wgt: City: Stale. Dl. / ID#. Zp. HAN Phone I/. Simmons #: Narrative: i'l0 1,/ 61C'r /1,115 byes 1 Time Yes 0 NIA Data Hair. Stale: Evidence Yes NO Court Date. Photos: Yes NO Deputy: # 7'0 Date: 03/67/// 4*:r Ille COLORADO MEMORANDUM TO: CHRISTIE PETERS, CTB FROM: DAN JOSEPH ENVIRONMENTAL HEALTH SERVICE SUBJECT: LIQUOR LICENSE INQUIRY DATE: MARCH 3, 2011 CC: CINDY SALAZAR; DEBRA ADAMSON In response to your request, Environmental Health Services has reviewed the Retail Food Service Establishment file for the Maravilla Restaurant, located at 13015 CR 16, in Fort Lupton, Colorado. At this time the Department is recommending for disapproval of the liquor license based on the facility's failure to maintain compliance with both the Colorado Retail Food Establishment Rules and Regulations and the Colorado Primary Drinking Water Regulations. Background Summary September 24, 2007 A Non -Community Ground Water (NCGW) inspection was conducted by Mark Thomas (Weld County) where the facility was cited for failing to have a certified operator for the system, did not have design approval and did not have detectable levels of chlorine. June 18, 2008 June 5, 2009 A NCGW inspection was conducted by Mark Thomas (Weld County) where the facility was cited for not having design approval, had higher than recommended levels of chlorine, and had multiple minor deficiencies. A NCGW inspection was conducted by Mark Thomas (Weld County) where the facility was cited for not having design approval, did not meet the required chlorination level, and had multiple minor deficiencies. Violation 5a (failure to maintain the water system in compliance with the Colorado Retail Food Establishment Rules and Regulation) was cited during this inspection by food inspection staff. January 15, 2010 March 29, 2010 July 23, 2010 August 18, 2010 January 14, 2011 January 21, 2011 The Colorado Department of Public Health and Environment met with Weld County Department of Public Health and Environment (Department) to discuss regulations concerning water systems that are related to Retail Food Establishments. It was determined during this meeting that enforcement can be conducted by the Department through use of the Colorado Retail Food Establishment Rules and Regulations. Department staff met with the Board of County Commissioners during a work session to discuss enforcement options. It was agreed that facilities should be cited and that enforcement procedures (as defined under food regulations) should be taken. Facility was cited for failing to maintain proper levels of chlorine through water treatment system (cited under food inspection program). In addition, a NCGW inspection was conducted where the facility was cited for failing to have a certified operator for the system. The NCGW inspection also noted 14 minor deficiencies during the inspection. The Colorado Department of Public Health and Environment Water Quality Division issued a letter stating that the nitrate exemption that the facility was operating under had been removed and that they system must come into compliance with the Colorado Primary Drinking Water Regulations. The facility could install additional equipment to treat the water for high nitrates or the facility could provide sampling data to show that the levels of nitrates were less than 10 mg/L. The exemption was removed since the facility was no longer able to meet the requirement of not serving children under 6 months of age. The facility also functions as an event center for large family events and celebrations. A follow-up inspection was conducted where the facility did not have a certified operator, had not submitted the required sampling (no bacteriological samples submitted), and was not treating the water for nitrates as required by the regulations. Facility was issued a First Notification of Non -Compliance for violation 5a (failure to maintain the water system in compliance with the Colorado Retail Food Establishment Rules and Regulations). 2 February 28, 2011 The facility was required in the August 18, 2010, letter to submit nitrates on a quarterly basis. The facility has not submitted a nitrate sample since receiving the letter. The last nitrate sample was submitted on March 4, 2010, and the facility had a nitrate concentration of 10.22 mg/L (higher than the level allowed). In addition, the Colorado Retail Food Establishment Rules and Regulations require that a bacteriological sample be submitted once per quarter. The last bacteriological sample was submitted on March 4, 2010. Should you have any questions regarding this matter, please contact me via e-mail at dioseph@co.weld.co.us or by phone at 970-304-6415 extension 2206. Thank you. Dan Joseph Environmental Specialist III 3 -)n O ca -o O 0 M O m m O O > m Co c m 0 O o 5 r - U o o at O Y m 3Uac7 oftb Tr RECEIPT DATE RECEIVED FROM r 0/,.,I/ ADDRESS E. V1 , a? : ) r. I„•. a f .era, .,� FOR !_E. 17‘c/- NO / ^,'� //`, c r:7: HOW PAID CASH CHECK /L;0 fu MONEY ORDER O V (U O 0 as m O O O T m c° c w to 0 o -F N. U 0 0 o d Y m ® N O N c.) o_ 4 v� RECEIPT DATE RECEIVED FROM ADDRESS c".0.3 T CW BY ao// S:NU.;4, L))y t r NO. 0 5 5 >,, .17 / L� tie J FORS + �L .2. (JI- /g va D CASH CHECK MONEY ORDER O -o ra 0oa N O N. O O a) • Y m a) O N U a 0 th BY CEIPT DATE .,1-i%•-,2O// NO. 0575 REEIVED FROM Jam Ai- Laic LGLui,/(0 . 4]14•, /�. ,"f �aH,' ADDRESS `-`^ A FOR RECEIPT O a m O O CoN Oct0 0 T m 00 • a)O o w U 0 a 0 a) 'O Y m a0 Uac7 -we v3ire WEI f1/7. i `. o Y $ )o a.. \�E`J/. .14/_)/././.. �7( BY DATE RECEIVED FROM KZ' ADDRESS =7' / 4/(1,F' Ati 17-0 % 0c/ //10 / �., ( • � FOR • h'�: /( b /'( BY NO. ✓�$ 146.,, , ?I1 1 0 O v N RECEIVED FROM o U o° ADDRESS T In I c a)OO • n U U • ° o aa) O Y m N N a) O 3 U d O rirme v� 3 0 V m O o M O ct 0 c • a)OO 0 o x U U o o aTi -0 y CO TO a) N O m Un.C7 j4 se RECEIPT DATE NO. FOR HOW PAID CASH CHECK MONEY ORDER RECEIPT RECEIVED FROM ADDRESS DATE BY NO. 8575 FOR HOW PAID CASH CHECK MONEY ORDER 0 -o m o o co U w 0 0 0 m co E w o o o x U ° o aTi y m C.)a0 (.4r:U F "S6 0 0 0 — 0° a co N RECEIVED FROM Oct 0 0 • ADDRESS ); m co C N OJ v O $ USo0 FOR RECEIPT RECEIVED FROM ADDRESS DATE BY No. 8575! 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J Recipient J Third Parry L Credit Card Li Cash/Check &p Sara Total Packages Total Weight Teel Declared Valuet S *onrothe smotee aoa, mew k oimrarbmambioca urrree iedExS moan Suiderincludmptenaethet maaoriiaTom e 8 Residential Delivery Signature Options awn require ang^more, check trrennrindrrect No Signature Required J Package may bells wbem Sbunnga signature tar delrve,y Rer Tate rmobPetalsemrlioNs-mm FaciEkkPRINTED IN USA.SPY Direct Signature e m patio Y 9nlm Porxt tvv rpm(. In direct Seq, nature ne one is a liable ramparts addracc, ata ghbx addressbay wror',Jesse; delivery. DATE C242Ci-$2 in k a O 520 1350 —tYC.82-26-1070 /`L+ I $ .5CJ._ eetteiflt e G) Forst National Bank 1 482-7771 an lath stionalbonk.corn FOR Weld County and State of Colorado Tavern Liquor Licenses for RJML, LLC, dba La Maravilla were picked up in person by Ruben J. Rodriquez on June 7, 2011. Witnessed by 6&)4--4--A-- �v , �� DepuClerk to the Board Hello