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pa <br />CERTIFICATION <br />The Applicant, Tomichi Materials, LLC <br />pe- a -- <br />(print applicant/company name), <br />by Byron R. Chrisman (print representative's name), as Manager <br />representative's title), does hereby certify that none within 200 feet <br />(print <br />(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 Tomichi Pit <br />File Number M- 2063 081 <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 />ACKNOWLEG Y: <br />Annlicant-'�Representative Name <br />Date Ae-ze e,/y Title -,V✓9-C <br />STATE OF <br />ss. <br />COUNTY OF P�, MGA- ) <br />St" <br />The foregoing was acknowledged before me this day of , , 2015, by <br />M iy ilctSl(YlC<<l of as ich� YIjCt`�'1 �C� <br />My Commission Expires: <br />otary�Pulic��� <br />JOANNA L HOFFMAN <br />Notary Public - Arizona <br />Pima County <br />`My Comm. Expires Oct 24, 2016 <br />