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• i <br /> r <br /> CERTIFICATION <br /> The Applicant, City of Fort Collins (print applicant/company name), <br /> i <br /> byti, leffrey Mi hel i ch (print representative's name),as De ut City Mana a (print <br /> ° �representative's title),does hereby certify that Great Western Railway st`ructure 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 Ripen 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 /> I <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> Applicant _ Ilk Representative Name T� V. k <br /> 1yuDate 0 — 1 Title Q <br /> rrr j i <br /> STATE OF <br /> COUNTY OF 1 )ss. <br /> The foregoin was cla�yppwledg before ie zis day of ,20 b <br /> Iola <br /> C.�l as ri1 <br /> My Commission Expires: r <br /> Notary Public <br /> SARA GONZALES <br /> NOTARY PUBLIC <br /> STATE OF COLORADO QF ®Rpc <br /> NOTARY ID 20014021847 :y a•'' "O` <br /> MY COMMISSION EXPIRES JULY 16,2017 V� a <br /> W <br /> a" <br /> Appr ed Form <br /> ssi nt eity Attorney <br />