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CERTIFICATION <br />The Applicant, .SW &"aa& (print applicant/company name}, <br />by 906a 6Hi'g�/ (print representative's name), ashit/3� P (print <br />representative's tine), does hereby certify that INTERMOUNTAIN REA (structure owner) shall <br />be compensated for any damage from the proposed mining operation to the above listed structum(s) <br />located on or within 200 feet of the proposed affected area described within Exhibit A, of the Reclamation <br />Permit Application for _ DE= %k A 14 lj i (operation aame)� <br />File Namber M-Z?H- -e-&' <br />Thin form has been approved by the Colorado Wined Land Reclamation Board pursuant to its <br />authority ander the Colorado Land Redantation Act for the Rxtraction ofCoasiructlon Materials and <br />Ike Colorado Mined Land Reclamation Act for Hard Rock, Meta 4 and Designated Mitring Operations <br />Any alteration or modyication to this form shall result in voiding this form <br />NOTARY FOR PERM N APPLICANT <br />ACKNOW.EGED BY: <br />Applicam 5]4,4"e <br />&,f Representative Nam f�/Jt1 ` +�'�,+�j(/ <br />Date / z 0/ 57- Title <br />STATE OF &At) <br />/ ) ss. <br />COUNTY OF <br />oregoin was acknowledged before me thisay of AIRZV20 '• ort '%``t'J <br />s as 06*66:::2 of <br />012 � si-!-�-r My Commission Expires: -9 - 1-7 <br />Notary Public <br />k DEBBIE J. SPEAR <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />NOTARY ID 19904016372 <br />"v ^s mmtSSION EXPWtES JUNE 4, 2017 <br />9'd 8809-Zti8-0L6 07 e6Uey0x3 � 0019enll db£:t,0 9 � 9 6 Inf <br />