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CERTIFICATION <br />The Applicant, (print applicanticompany name), <br />by �1,�lA1 d?ir,2/ti (print representative's name), as a (print <br />representative's title), does hereby certify that �fir/1P� (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 Q��1 It i �� (operation name), <br />File Dumber M -• <br />This form has been approved by the Colorado MFned 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 Aci for Hard Rock, Metal, and Designated Mining Operations. <br />Ant, alteration or modification to this form shalt result in voiding this form. <br />NOTARY FOR PERMIT APPLICANT <br />ACKNO'WLEGED BY: <br />Applicant .J4 C Representative Name�l3/l� (1�G <br />r� � <br />Date �/' Title %t mbe'r <br />STATE OF <br />ss. <br />COUNTY OF l% ) <br />Ufl regoing was acknowledged before me this�%ay of , 20 ,Sb <br />as °f <br />�. My Commission Expires: <br />Notary Pub • <br />� -t1—! 7 <br />DEBBIE J. SPEAR <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />NOTARY ID 1 9904016372 <br />MY COMMISSION EXPIRES JUNE 4,20`17 <br />6'd 8805-Zb8-OL6 011e6uey0x3�00;saAll dq£:b05l9llnf <br />