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The Applicant, <br />CERTIFICATION <br />ap licant/company name), <br />by (print representative's name), as VO t, Z CLC T cif (Print <br />representative's title), does hereby certify that NJ A "t, 1r�S t� ��O S- 5 (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 Ross Pit <br />File Number M- 1990 134 <br />(operation name), <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 />ACKNOW GED BY: <br />Applicant L Q S <br />Date �� " C-r) S — Ci -Z <br />Representative Name <br />Title a <br />STATE OF O►'Gar U ) <br />} ) ss. <br />COUNTY OF <br />T e foregoin w�,D� acknowledged before me this day of nt;) � , 2013 , by <br />C1ryl/ -S R - as () ( "o -Q ✓ of , <br />l , <br />S r 1 V• My Commission Expires: <br />otary Publi <br />ASHLEY M. GREEN <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />NOTWf 0 #20094022648 <br />My Commission Expires July 8, 2017 <br />