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CERTIFICATION <br />The Applicant, Lo Zi 8 c r La r.. d q- 0,0,-4- � I e- CoUtpprint applicant/company name), <br />by -Cit -1 s5 U' et1 (print representative's name), as tanager (print <br />representative's title), does hereby certify that OujgmE & =ltiAN (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 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 />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 4- (iiMF <br />(o Representative Name 1 <br />Date �z t ;3 Title V. i. <br />STATE OF GOLO e-AW ) <br />ss. <br />COUNTY OF 1" L0& 12d <br />The foregoing was acknowledged before me this Z- day of u 20 by <br />-jAL1 ,ju.7Tf.Nj as &W e,°rL pAe -TNV--of g 1pA)z LAwb�,CATI1S to l 1 IF <br />Expires:_ 1141,-Zolt, <br />