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CERTIFICATION <br />The Applicant,�PG�QTP_ (print applicanticompany name), <br />by &A) (1i( / (print representative's name) as W -r— (print <br />representative's title), does hereby certify that hen {structure owner) shall <br />be compensated for any damage from the proposed mining operation to the above listed structures) <br />located on or within 200 feet of the proposed affected area described within Exhibit A, of the Reclamation <br />Permit Application for rat) / f (operation name). <br />File Number M - <br />This form has been approved by the Colorado Mined Land Reclani Ition 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, Meta4 and Designated Mining Operations. <br />Any alteration or modi,Jication to this form shall result in voiding this form. <br />NOTARY FOR PERMIT APPLICANT <br />ACKNOWLEGED BY: / j <br />Applican�� ale- Lc� Representative Name <br />��B/A1 <br />Date -r` tj "! i Title s <br />STATE OF ( _} <br />ss. <br />COUNTY OF 0- 6 ) <br />,Tbe fore oin was acknowledged before me thisday of 20 5, b <br />n fP YU1Q t1 as LL- C- <br />C-�,,-�Y My Commission Expires: <br />Notary Publi <br />DEBBIE J. SPEAR .� <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />NOTARY ID 19904016372 <br />MY COMMISSION EXPIRES JUNE 4, 2017 <br />£b'd 8808-Zt,8-OL6 011 e6U8g0X3 {oolsenil d9£:b09l 9l lnf <br />