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CERTIFICATION <br /> The Applicant, �; it] f�ktVeW -1 / SSE t nom, (print applicant/company name), <br /> by 15c °F (print representative's name),as (print <br /> representative's title),does hereby certify that � (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 (operation name), <br /> File Number M-1W,-- 0-3 1 . <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 Operadonx <br /> Any alteration or modification to this form shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> Applicant P h p C, L z cj Q MoLn Representative Name S cc,i+ \tj�s f <br /> Date Title---Q J� 0;r- <br /> STATE OF <br /> )ss. <br /> COUNTY OF <br /> The foregoing was acknowledged before me this t3 day of i-e b r 'c 20 I by <br /> P1,- 1 �� E. �yv� e. oasti�-r� c�Yr of 'osx , lrc. <br /> Jia�V'JLV 1,A--vv vqvr, <br /> nus <br /> sion Expires: o rte t.- <br /> Notary Public <br /> FLORENCE HAUPTMANN <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20094034972 <br /> MY COMMISSION EXPIRES OCTOW 19,9017 <br /> a <br />