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CERTIFICATION <br />The Applicant, l.WVtj-0 C—Vn- --1 , Ll_C (print applicant/company name), <br />by n(L�tin (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� �� c��-C� Up_i . u - -+ (operation name), <br />File Number M- aWr 0 71 <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� 1 /� �'�Ct C l�Qy�' - Representative Name Oce -kir, cl <br />Date (C - I I - I V <br />STATE OF C G lbVc-d-y ) <br />) ss. <br />COUNTY OF �AS SC, ) <br />Title (e S 1 CU, ,j <br />KHRISTEN GONZALES-QUINTERO <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />NOTARY ID #20154012496 <br />My Comm fission Expires March 27, 2019 <br />The foregoing was acknowledged before rtigTRB—'Rclay of ` , 20±j by <br />JNJ ►� �i t as CQ S O -C. ��-k of i LA2lCU1d C YCL U e (, L - L -C, <br />My Commission Expires: 3, < <� <br />Notary Public <br />