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CERTIFICATION <br />The Applicant, Lazy H Inc (print applicant /company name), <br />by William K. Havengar (print representative's name), as Owner (print <br />representative's title), does hereby certify that Henrylyn Irrigation District (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 Bootleg Quarry <br />File Number M- <br />(operation name), <br />This form has been approved by the Colorado Mined Land Reclamation Board prersuant 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 />NOTAR17 FOR PERMIT APPLICANT <br />ACKNOWLEGED BY: l f <br />Applicant YLO Representative Name <br />Date _q] �� 1 t �$ Title <br />STATE OF (nlnJr6db ) <br />) ss. <br />COUNTY OF ) <br />The foregoing was acknowledged before me this )'� day of , 20_L5, by <br />k o,kil;un, k ate. .r as oto*,or of Lem „ <br />V— _ My Commission Expires: <br />Notary Public <br />Susan K Kwanon <br />Notary Public <br />state of Cokm ado <br />Notary ID 20044041221 <br />d!flmlgsien December 24, 2016 <br />