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t <br /> ` CERTIFICATION <br /> V <br /> The Applicant, City of Fort Collins (print applicant/company name), <br /> by Jeffrey Mihelich (print representative's name), as Deputy City Manager (print <br /> representative's title), does hereby certify that Box Elder Ditch Company (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 East Rigden Pit (operation name), <br /> File Number M-1979-097 . <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 /> Applican Representative Name J C V t C <br /> r� <br /> Date V1 Title <br /> STATE OF CO <br /> ss. <br /> COUNTY OF I <br /> The foregoing wa ac o led before me i day of �t— , 20 by r <br /> i ( as <br /> My Commission Expires: <br /> Notary Public <br /> SARA GONZALES <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20014021847 .�0�•'"'" °�°��. <br /> MY COMMISSION EXPIRES JULY 16,2017 ° <- <br /> ATTEST: V° „� � '-z <br /> Appr ve To Form pity cierk ° <br /> r°..> }` <br /> ssis nt City ttorney _:�-•�' A <br />