2014-06-25_PERMIT FILE - M2014033

• Permit No: M2014033
• IBM Index Class Name: PERMIT FILE
• Doc Date: 6/25/2014
• Doc Name: New application
• From: Four X Ranch, Inc.
• To: DRMS
• Email Name: TAK
• Media Type: D
• Archive: No

CERTIFICATION
The Applicant,
(print applicant/company name),
by (print representative's name), as President (print
representative's title), does hereby certify that (structure owner) shall
be compensated for any damage from the proposed mining operation to the above listed structure(s)
located on or within 200 feet of the proposed affected area described within Exhibit A, of the Reclamation
Permit Application for Four X Ranch Gravel Pit
File Number M-
(operation name),
This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its
authority under the Colorado Land Reclamation Act for the Extraction of Construction Materials and
the Colorado Mined Land Reclamation Act for Hard Rock, Metal, and Designated Mining Operations.
Any alteration or modification to this form shall result in voiding this form.
NOTARY FOR PERMIT APPLICANT
ACKNOWLEGED BY:
Applicant
Date
STATE OF )
ss.
COUNTY OF )
Representative Name
Title
The foregoing was acknowledged before me this day of _
as of
My Commission Expires:
Notary Public
20, by