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C ERTI WATION <br />The Applicant, L.Az q K 3 ccr Lo n d q., C 4+ { 2 C4�qfprint applicant/company name), <br />b3'— �_k.1'±� (print rCprCSMtatIve,'s name), as Manager <br />representative's title), noes hereby certify that lL4ir ��E_xP,yt; -k� (structure owner) shall <br />be compensated for any damage from the proposed training operation to the above listed structurc(s) <br />located on or within 200 feet of the proposed affected area described within Exhibit A, of the Reclamation <br />Permit Application: for Uncompahgre Pit <br />File Number M- 2013_ -007, <br />(operation name), <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 />Ike Colorado Mined ,Land Reclanuttion Aet for Hard Rock, Metal, and Designated Mining Ltperations. <br />Any alteration or modification 10 this form shall result in voiding this farm <br />NOTARY FOR PERMIT APPLICANT <br />ACKNOWLEGED BY: <br />Applicant txl;ti C {'x ��'t��d (Ai7�a' (llt' Representative Flame' 1 f <br />Date � "z. ��c.�_ Title <br />STATEOF (-oL0RADO ) <br />COUNTY OF _M of i RD`,41 ySs <br />The foregoing was acknowledged before me this f Z day of ri l3K i,l �• 20 1! <br />�5 by <br />SAY WrOt*J as C,►,i �a L PAj, TQL of_tA�t -1 K 5A? � n CO l ! 1p <br />Public; ` <br />ppOyEfW a . <br />CH�yEM _ <br />mission Expires___ 1194 12-o ( �, <br />