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CERTIFICATION <br />The Applicant, I-j M �S'Tti'! CC -flW sr�iy� W HD�ii� Z�/e • (print applicant/company name), <br />by 1 jK S3T21(': Cf> w (print representative's name), as P/2 F S'I /JT"-r (print <br />representative's title), does hereby certify that Ohio "NAW A-k.ioQM E CO(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 )3gV .+rAJS'T0W C aL),j PRN (operation name), <br />File Number M -Dr25- -jYi2- <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 STCW ��l i }G�PtS ffIX, )�+.)C Representative Name )m �Tw)C— C -0lh/ <br />Date 2 ' Zt9 - >S' Title )1j.FA/I- <br />STATE OF COCnedt,40 ) <br />ss. <br />COUNTY OF (*z1wjeji?, ) <br />The foregoing was acknowledged before me thie;6��day of �+( 20� by <br />Nec,u - Th,�_d,E as r of <br />' My Commission Expires: 12-12-'F 5 <br />Notary Public <br />RrT�r�� <br />USLICI *10 <br />covo <br />