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CERTIFICATION <br />The Applicant, R'Ne 4, C*Q,ri4 — ;pow }c C�s �� (print applicant/company name), <br />by i l , F. )4- (print representative's name), as 'Pew (print <br />representative's title), does hereby certify that 7)10 ryki, , r'.:_� (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 area described within Exhibit A, of the Reclamation <br />Permit Application for r x`71 r,'T (operation name), <br />File Number M- <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 />ACKNO WLEGED BY: <br />Applicant' gl„ ( -„��,, 9�C— xcln� 1�,RepresentativeName <br />Date _� _ 1 . aC�1 Title <br />STATE OF _ ) <br />ss. <br />COUNTY OF <br />The foregoing was acknowledged before me this day of )^ n� , 20�, by <br />-:E� 1 e r P. t q as _ ��le_� c �,� of of Q .r L), C, ^ 1; r•5 . �� <br />ah �, cam, My Commission Expires: 1;4 - ?�► - <br />` 6tary Public <br />DDT O;rH E.. W.)RGRN — NOTARY PUB <br />COUNTi'Y + S TATE OF <br />H± i f41� �"dYOMI <br />N Commission Ex Tres ► -3 -1 <br />