Laserfiche WebLink
RECEIVED <br />JAN 26 2015 <br />CERTIFICATION D1VLSM OF RECL4MAW0j <br />NNW AND SAFEW <br />The Applicant, 5-A t t c- (print applicant/company name), <br />by:: ,LBi(� Vf�'.L�rYY�iv (print representative's name), as {�lyl (- (print <br />representative's title), does hereby certify that (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 I�67 t{ Q a (_ pl i- (operation name), <br />File Number M- Mg f0Q <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 />( <br />Applicant 5A- , r Representative Name(jBI10 VP-eC-6L,q70 <br />Date 626 f S Title M(�y_l�t,C� et <br />STATE OF - Oiro -dO ) <br />ss. <br />COUNTY OF <br />T- la�f�orLeg�oing w��k�n'owle aged before me thiso� day of o f _ , 20�, by <br />My Commission Expires: ! ! �T� /4, <br />Nota6 Public <br />LONONARMPUBLiDEZ <br />STATE OF COLORADO <br />NOTARY ID 20004034734 <br />MY COMMIS SION EXPIRES 11.2T -2016 <br />