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CERTIFICATION <br />The Applicant, �pk ©r�G/LAj1 �� L (print applicant/company name), <br />by IOWA, 1I9, C`6 (print representative's name), as (print <br />representative's title), does hereby certify that f -v4'11 ,yCL' (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 T fyi�; "11,C N OWL[- L[-IV'I,T (operation name), <br />File Number M -W- 0-1 <br />This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its <br />authority under the Colorado Land Reclamation Actfor the Extraction of Construction Materials and <br />the Colorado Mined Land Reclamation Actfor 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 ��il ... Representative Name '/� t' <br />Date 1J71)o/ 5 Title <br />STATE OF ) <br />C✓C ) SS.PUB4� DEE ANN LAMBERT <br />Notary Public, State of Texas <br />COUNTY OF ) My Commission Expires <br />December 19, 2016 <br />The foregoing was acknowledged before me this day of 2 , by <br />//AVIf7(�iZJr-P) M as G% L3 of - /-`�/af�1'1 G -&C <br />My Commission Expires: f -�— `fes /,,// <br />Public <br />