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CERTIFICATION <br />The Applicant, /,A:iiinq GoRr►p �K (print applicant/company name), <br />by M1Qe Q)yjE%L0" (print representative's name), as (print <br />representative's title), does hereby certify that v -F CvCo6U:uAo (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 <br />File Number M -%48c3,-14( <br />c— {" 4 coi.� N>a <br />(operation name), <br />This 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 Colorado Mined Land Reclamation Act for Hard Rock, Metal, and Designated Mining Operations <br />Any alteration or modification to this form shall result in voiding this form. <br />NOTARY FOR PERNIIT APPLICANT <br />ACKNOWLEGED BY: / <br />Applicant(�-p to"/--�s �y Representative Nam <br />Date 7 /l�//� Title 1�- <br />STATE OF <br />ss. <br />COUNTY OF�,��; ) <br />The foregoing was acknowledged before me this (z day of u lt4 20 (5, by <br />j('kw `f4ygg.,A �,wkmas �l[tc�uJ��� �'lQr.,i u_ of i�clCkc�c� V�liil�n� (`C <br />My Commission Expires: k:-50 - -,;Lo 18 <br />Notary Public <br />MEGAN G FREYSCHLAG <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />NOTARY IIS 20144025710 <br />MY COMMISSION EXPIRES JUNE 30,201 a <br />