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OCT 1 4 2314 <br /> CERTIFICATION <br /> The Applicant, 111aMA Gounl7y /1�o,9c� /�ry� Rld G (print applicant/company name), <br /> by//.W,gw Afrjl io I's _(print representative's name), as TRucK ffNd facer ,A/y(print <br /> representative's title), does hereby certify that J4N NAoQsSl�lEE G1g6 NoRn/ (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 8RArUc/ 1 j T (operation name), <br /> File Number M-/V1 - 25 0 <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: � aij�/ ' <br /> Applicant( 1C rr,, ,(cCiXl-LI Representative Name n Y\l S <br /> Date C� - - L� Title-A r'y,cV` ��� �G re vv�t� ►1 <br /> STATE OF CCAUC'C,,Jg ) <br /> ss. <br /> COUNTY OF V Q\ ) <br /> The foregoing was ascknowledged before me this:0 day of So 04- , 20 �L�,by <br /> kNa),3CA(k asTrti,cl��r 1�n�h�nChF c,rti �Pf��w�v'c'�ci..,� � �ec+t�' V::)Dd qk <br /> 1-\ L1 My Commission Expires: - 1 - <br /> Notary Public <br /> NANCY L WRIGHT <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 19934019442 <br /> MY COMMISSION EXPIRES APRIL 1,2018 <br />