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CERTIFICATION <br />The Applicant, 7'j;lM N L.A{,!—IA Pcu.A2g 19916&1 (b A (rint applicant/company name), <br />by/� i�(r i3GtN(,e-NBLY� (print representative's name), as R2ESlogNf (print <br />representative's title), does hereby certify that $RIkNNl. ,3, a e76-fJ (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 01�W GA-t—K *211*t TMA(L &p I (operation name), <br />File Number M - W15 - 003. <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 Representative Name M Illi ;+Vuj6&-AL8tye6 <br />Date Cj -1 li,- 6 Title PieO?>, /,P*,EW t %- <br />STATE OF C©LDIZA> 0 ) <br />ss. <br />COUNTY OF - ) <br />The foregoing was acknowledged fore me thisday of %l , 2015tA , by f <br />lY% ( CL uN�6lJB�2�as t� 5 ►�E�t i of/,�� /1/ w RGNE JAP�oP4C �p IGA�r/� Co <br />A. GPFR%,,� <br />' <br />Commission Expires. �� /,� 4:•'__'• <br />�� min �.fuav f <br />Notary Public�Q ; O T A R y: x <br />t� <br />Nj,'. 'URLO <br />