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CERTIFICATION <br />The Applicant, 0,;//n,6 jaw zm �F - - f , Ll� (print applicant/company name), <br />by �r�� h ,y1/ -1 (print representatives name), as 67/, ✓ (print <br />representative's title), does hereby certify that '7u-le-r- , �,r�d it (structure owner) shall <br />be compensated for any damage from the proposed mining operation to the above listed structure(s) <br />located on or within 200 feet of the proposed affected aread /escribed within Exhibit A, of the Reclamation <br />Permit Application for 11--e (operation name), <br />File Number <br />This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its <br />authority under the Colorado Land Reclamation Act for the Extraction of Construction Materials and <br />the Colorado Mined Land Reclamation Act for Hard Rock, Metal, and Designated Mining Operations. <br />Any alteration or modification to this form shall result in voiding this form. <br />NOTARY FOR PERMIT APPLICANT <br />ACKNOWLEGED BY: <br />Applicant kg6 V u Represe <br />G <br />Date Title/ <br />STATE OF 611,9 4'0 ) <br />ss. <br />COUNTY OF . 0 ' ) <br />The foregoing was acknowledged before me this.?/ day of `�, 20LZ, by T� <br />_Rria n of �— /ter <br />iL <br />W", zq, C <br />My Commission Expires: <br />Notary-Public' <br />otary blic <br />RANDALL D. SCHAFER� ! <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />NOTARY ID 19954016062 <br />MY COMMISSION EXPIRES 12/06 /�t1� { <br />