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CERTIFICATION <br />The Applicant, <br />(print applicant/company name), <br />by (print representative's name), as (print <br />representative's title), does hereby certify that <br />(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 <br />File Number M- <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 />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 />Applicant <br />Date <br />STATE OF ) <br />) ss. <br />COUNTY OF ) <br />Representative Name <br />Title <br />The foregoing was acknowledged before me this day of _ <br />as of <br />Notary Public <br />My Commission Expires: <br />20_, by <br />