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CERTIFICATION <br /> The Applicant, /le/44vi/e 42.42///' �L'�, (print applicant/company name), <br /> by44fx, a." //©,a s (print representative's name), as 4 (print <br /> representative's title), does hereby certify that ,YL- � (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 /i4 en - // /c�G����' �� (operation name), <br /> File Number M-20j'/-666. <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 /> nk.V0.CK0.U1«e YlC0 r2) L,LC <br /> Applicant v k 'en n t Representative Name elf e '\Vkr W1\5 <br /> Date E CQ\Y\ C' 1 9) Title 0\ CSZ �^QS lV1 @ Y� I ' `kyv`d <br /> STATE OF �\p ) <br /> ss. <br /> COUNTY OF t )k,)(\ ) <br /> The foregoing was acknowledged before me this day of QCmIrtsd- , 201 y, by <br /> , <br /> J s\&& i'I,\elkVi1IVQ.M..as UiceFPresictsx fr\ r of NN,votdAvitlk Y�C1't <br /> My Commission Expires: \C:\ <br /> Notary Public <br /> ..:. SHARON E. CATE <br /> NOTARY PUBLIC <br /> ti STATE OF COLORADO <br /> NOTARY ID 19984003352 ti <br /> MY COMMISSION EXPIRES FEBRUARY 19,2018 <br />