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CERTIFICATION <br />The Applicant, lWOM Gi'Q—Ld , LLC (print applicant/company name), <br />by_QajWn bryi_ D ,A? (print representative's name), as Ores; &-v,A (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 L 1C Vyt l�V'CUP_I . �I (operation name), <br />File Number M- 2bO'�'- 011 <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 Actfor 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 � � C-1-ya AW—C Representative Name ()04ilcin <br />Date Title V(Q S t <br />STATE OF C C 1 bVC-Ic-to ) KHRISTEN GONZALES-QUINTERO <br />) ss. NOTARY PUBLIC <br />COUNTY OF �5C, ) STATE OF COLORADO <br />NOTARY ID #20154012496' <br />My Commsion Expires M rch 27, 2019 <br />The foregoing was acknowledged before ay o , 20�, by <br />Y1At nyiv\j�1p- as 9(OSO-Ctk of l LjQICuA (2rC Ue_(, LLC- <br />My Commission Expires: <br />Notary Public <br />