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CERTIFICATION <br />The App licant, -d, oLh- } rz, (print applicant/company name), <br />by ► � 1 r f F . (print representative's name), as (print <br />representative's title), does hereby certify that 7)1 a j , t,' (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 /, ) ZT1 �7� �,' (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 />ACKNOWLEGED BY: <br />Applicants` Name <br />Date_ .DUZ Title 5;Az ,-V <br />STATE OF _ ) <br />ss. <br />COUNTY OF n ) <br />The foregoing was acknowledged before me this_ day of . , 20 I-A , by <br />as of � . �t� �k .f Ex C� . 1r�1; r• 5 �,� . <br />My Commission Expires: t <br />otary Public <br />fORAH P.. MORGAN - NOTARY PUBLIC <br />UNTY ,: i- STATE OF <br />k*1;If� lE W YOMING <br />N l:ommissinn Ex Tres ! - 3 -1 <br />