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CERTIFICATION <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 /> Applic Representative Name��` V o c <br /> Datean I t —14 Title <br /> STATE OF CC) r ) • <br /> � )ss. <br /> COUNTY OF ) ¢¢�� <br /> The forpgomma ac o led befor ,me i V day of / ,24 b <br /> as S <br /> My Commission Expires: <br /> Notary .Pulic <br /> SARA GONZALES <br /> NOTARY PUBLIC <br /> STATE OF COLORADO OF f oR T c <br /> NOTARY ID 20014021847 .� •°• ••°O� <br /> MY COMMI SM EXPIRES JULY 16,2017 <br /> ATTEST. <br /> Appr v To Form City Clerk <br /> °°•a•.°e°•°V <br /> ssis ntcityAttorney � <br />