Laserfiche WebLink
CERTIFICATION <br />The Applicant/, 6- hmee- <br />_(print applicant/company name), <br />by fDhji) int representative's name), as A�E^IyZfz . (print <br />representative's title), does hereby certify that ' -PI�a"� (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 for4&,, �:_�f ' (operation name), <br />File Number M-ffp <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 PERMIT APPLICANT <br />ACKNOWLEGED BY: <br />Applicant , � �% A-, le$�a le GG C_ Representative Name <br />Date `� - 3 - (� Title <br />STATE OF <br />) ss. <br />COUNTY OF_M ) <br />The foregoing was acknowledged before me this -:!>I5f day of .20(S-. <br />by <br />olo,r def as-- of <br />My Commission Expires: E' y' 1-7 <br />Notary Public <br />DEBBIE J. SPEAR <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />NOTARY ID 19904016372 <br />MY COMMISSION EXPIRES JUNE 4, 2017 <br />