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CERTIFICATION <br />The A licant, G (print applicant/company name). <br />by oOM?& 2% (Print representative's name). as #,,g __(print <br />representative's title), does hereby certify that ;,, dep ka � tae (structure owner) shall <br />be compensated for any damage from the proposed mining operation to the above listed structure(s) <br />located on or witnin 200 feet of the proposed affected area described within Exhibit A, of the Reclamation <br />Permit Application for 11QP.?d. /i _ T_ (operation name), <br />File Number M <br />This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its <br />authority under the Colorado Land Reclamation Act far 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 resuh in voiding this forth <br />NOTARY FOR PERMIT APPLICANT <br />ACKNOWLEGED BY: <br />A licant G,6'!/IJ ,� �C�lA� Representative Nae <br />c; <br />PP � lm_ <br />Date r=,� �,� Title it <br />STATE OF C'c/Vq---)-0 ) <br />) ss. <br />COUNTY OF-y"Or__ _ `_) <br />he foregoing was acknowledged before me this 15' day of , 2015 . by <br />obi -,L lea, : u -F Y, as of 5g E�J t- <br />-4- My Commission Expires: <br />Notary Public <br />DEBBIE J. SPEAR <br />NOTARY PUBLIC <br />STATE OF COLORADO j <br />NOTARY tD 1 99 0441 6372 <br />,M' iCOWSSION EXPIRES JUNE 4. <br />£'d 9809-Zt,9-OL6 C)J� e6ue4ox3 Noo;senjl dt7£:t,0 9 L 9 L Inf <br />