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CERTIFICATION <br />The Applicant, R C. 1/, bd-ffo e-) L_ L_C (print applicant/company name), <br />by Aga r& L ., (print representative's name), as print <br />representative's title), does hereby certify that L3 j cc- {C 14"115 Emar y (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 ,rte oc>tte- { P. f" (operation name). <br />File Number M- !9 �. <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 firm. <br />NOTARY FOR PERMIT APPLICANT <br />ACKNOWLEGED BY: <br />Applicant oc �� (j o Jqo ci L LC Representative Name Nj re <br />Date Title f'1 <br />STATE OF CO «o ) <br />ss. <br />COUNTY OF ) +t_� <br />The foregoing was acknowledged before me this 110q day of 4GCZ.r\ , 206, by <br />f%4- , 9�n as t�P i+�t��2- of c �a4ar�.LLC. <br />My Commission Expires: a Nov 0Zo 18 <br />Notary Iyublicj <br />KARYL- LYNNJORDEN <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />NOTARY ID 20144044902 <br />My Commission Expires 11 -21 -2018 <br />