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CERTIFICATION <br />The Applicant, (print applicant/company name), <br />by (print representative's name), as (print <br />representative's title), does hereby certify that (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 <br />File Number M-JC0X -_N9. <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 />ACKNOWLEGED BY: <br />Applicant l,'jw fa ���CLU2` �! �_L Representative Name 13CW'1c-u'1 VA(AcL"IC <br />Date � • t l ., I C5 Title 'Vr( stct bLj <br />STATE OF � tF,, �- ) ? KHRISTEN GONZALES-QUINTERO <br />NOTARY PUBLIC <br />) ss. STATE OF COLORADO <br />COUNTY OF MQSC\ ) NOTARY ID #20154012496 <br />-mmission Expires March 27, 2019 <br />The foregoing was acknowledged before me this day of WN_CL_ , 20 j S, by <br />0QA-,axe yLi.dyl Q_ as PreS\J.� of I Li2 IaPd C rra1)e l _ L <br />��1e/�' �ixi_��Tt ii My Commission Expires: <br />Notary Public <br />