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CERTIFICAM <br />'1'lte Applicant, Lazy X t3 ar Lqf4 d- Cad 1. �C p&t w cant y n��,c }, <br />by CA (print represcxiWve's nme), as Manager (print <br />representa{ave's title), does hereby axtify that V-T- i c ;mot i V WA ri (strut = owner) shall <br />be a mpensaftd for any damage front the proposed mining operation to the above listed shiwAure(s) <br />located on or within 200 feet of the proposed affected area descn'bod within Exhibit A, of the Reclamation <br />Permit Applioa for Uncompahgre Pik (operation name), <br />Fite Number M- 2013 --007, <br />71* form has been moved by the Coivrado A9m d Land RerAa;nadvn BmW pw=wd to its <br />author# under the O*r ade Land R=&mw ivn Aet for aw Famcdon of Cenoucdm Marffkk and <br />Me Cakrado 1ldined Land RwA mdkw Act far Hard Ra* Afda4 and DedpiMed Mining im <br />Any atterad en or modtjaat vn to this form sit resalt in widEV this farm <br />1 I I � will <br />ACKNOWLEG l;D BY: <br />Applicant 4\71q Giro cad' <br />STATE OF CO LDFA 00 <br />ss. <br />COUN'T'Y OF H Ou i RD <br />Reprewnt Wm Name .✓ <br />Title �� ,� r4�'2< �r A' L- <br />was acknowledged before me this t Z day of PUWMA 20 i S, by <br />6i �+�1 -!oaf LA-57,89 4< &°g t.lW t? .'t1"L& CD t t t p <br />;Wnrawon Expires: 1 L�x.01 (-I <br />