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• i <br /> i <br /> CERTIFICATION <br /> The Applicant, Cly of Fort Collins (print applicant/company name), <br /> bY1 -]effrey Mi hel i ch (print representative's name),as De ut City M. a (print <br /> representative's title),does hereby certify that Great Western Railway ak �Zture owner)shall <br /> be compensated for any damage from the proposed mining operation to the above listed structures) <br /> located on or within 200 feet of the proposed affected area described within Exhibit A,of the Reclamation , <br /> Permit Application for East Ri en 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 modilcation to this form shall result in voiding this form. �. <br /> t <br /> NOTARY FOR PERMIT APPLICANT <br /> I <br /> ACKNOWLEGED BY: <br /> Applicant Representative Name V ;C f <br /> Date i' Titlegk) f <br /> i <br /> STATE OF �O <br /> )ss. <br /> COUNTY OF ) <br /> �i <br /> 1 <br /> The fore oin k wled before a is da of ,20 b <br /> -� g <br /> was•e. �c�l as y <br /> My Commission Expires: j <br /> Notary Public <br /> SARA GONZALES i <br /> NOTARY PUBLIC <br /> STATE OF COLORADO pF FOR t•�o <br /> NOTARY ID 20014021847 <br /> W COMMISSION EXPIRES JULY 16,2017 <br /> . SEAL <br /> AT'iTEST: <br /> . m. <br /> Appr ed Form <br /> Assisl. nt L01tV Attorney <br />