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FROM <br />CTl[E >PAJQ 16 2014 14: e6 /ST. 14:CSE INo. 7620439748 P 1 <br />Tubufl( ie#;w C_Ox C0'*;?w0'Yi 1-1-L <br />CERTIFICATION <br />The Applicant, HUERCANO COUNTY GOVERNMENT (print applicant/company name), by <br />(print representative`s name), as <br />(print representative's title), does hereby certify that rut— owner) <br />shall be compensated for any ckimage from the proposed training 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 <br />Reclamation Permit Application for PEAK VIEW GRAVEL PIT {operation name), <br />This form has been approved by the Colorado Mined Land.Redamation Board pursuant to-ks <br />auararity under the Colorado Land Reclamation Act forthe Extracdon of Construed n M &Wia[s <br />and the Colorado Muted Land Reclamation Act for Band Rock, Metal, and Designated Muring <br />Operations. Any alteration or mod(fleadon to this form. shat! rwdt in voiding this form. <br />ACKNOWLEDGED BY. <br />Applicant: HUERFANO COUNTY GOVERNMENT <br />Representative Name John Galusha <br />5igned: ' , <br />L_Doe 8/19/14 Title County Administrator <br />Representative Name Edward R. Garcia <br />Signed:, & A -! Date 8/19/14 Title Commissioner <br />Representative Namc Max Vezzani <br />Signed: Date--V19/14 Title Commissioner <br />STATE OF 4> <br />} ss. <br />COUNTY O <br />foregoing was acknowledged Fore me thisL day of . 20L, by <br />as <br />of C1%1//USS IUYIt.� <br />1 <br />Notary Public , My Commission Expires <br />DENISE Yt L <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />NOTARY. fD aalM1e <br />MY lit+ 2015 <br />