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CERTIFICATION <br />G it ILL {print applicant/company name}, <br />The Applicant, ,-')--A <br />b(print representative's name), a(print <br />representative's title), does hereby certify that y LC _ �-�- _(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�2 (operation name), <br />File Number M-A3-9?--O-qQ <br />27ris 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 Coloraido Mined Land Reclamation Act for Hard Rock, Metal, and Designated Mining Operations. <br />Any akeration or modification to this form shall result in voiding this form. <br />NOTARY FOR PERMIT APPLICANT' <br />ACKNOWLEGED BY: , r <br />Applicant I IftAAP Representative Name �f lt1 V t <br />Date 4W—SC"10 <br />/ S Title i� P�l>�.�a e►' <br />STATE OF &0,r(&,0 DSD ) <br />i�_ )ss. <br />COUNTY OF g-- —'�60^1_ ) <br />foregoin was acknowledged before me thisv�o2 day of 20�, by <br />as rndJt�- of <br />-fi My Commission Expires: <br />-R-ota6 Public <br />LORENA MELENDEZ <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />NOTARy 1012009034134 <br />MY 06MM18810N EXPIRSS t12T-2016 <br />9L'd 9909-Zb8-OL6 011e6uey0x3i{00tseni� d8£:t,0919Linf <br />