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CERTIFICATION <br />The Applicant, ko"s 011i 45 J�t. (print applicanticompany name), <br />by ILM Alplda� (print representative's name), as dGt3mr (print <br />representative's title), does hereby certify that P -(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 N/ Al" AWS/V A <br />(operation name), <br />File Number M -2jo -WI. <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 Ope► ations. <br />Any alteration or modification to this form shall result in voiding this form. <br />NOTARY FOR PERMIT APPLICANT <br />ACKNOWLEGED BY: <br />Applicant Representative Name Ala /au.H� <br />Date y Title <br />7 / dGJ »�r' <br />STATE OF 6) 1011.04) 1 <br />ss. <br />COUNTY OF At'tosi ) <br />The foregoing was acknowledged before me this 7 day of ^i <br />fl , 20 IS, by <br />BM2a <br />Mal as 6wiler of Mork /KkSN P � <br />JA <br />My Commission Expires: 7/3011 <br />Notary Public <br />STATE 00 COLORADO <br />NOTARY ID 19984017165 <br />i�iY COMMISSION EXPIRES JULY <br />30.2018 <br />