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CERTIFICATION <br />The Applicant, Sedgwick County (print applicant/company name), <br />by �� t(print representative's name), as ,,t !damy- <br />(print representative's title), does hereby certify that Black Raven Energy, Inc. (structure owner) <br />shall 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 Sedgwick County Skold Gravel Pit (operation name), <br />File Number M-1998-032. <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 the <br />Colorado Mined Land Reclamation Act for Hard Rock, Metal, and Designated Mining Operations. Any <br />alteration or modification to this form shall result in voiding this form. <br />NOTARY FOR PERMIT APPLICANT <br />ACKNOWLEGED BY: <br />Applicant Sedgwick County Representative Name 12t, .4 RIO- <br />Date: <br />D i Title <br />STATE OF COLORADO ) <br />COUNTY OF SEDGWICK ) <br />The foregoing was acknowledged before me this 1a-�A. day of _ August , 2015, by <br />as �y nor of �c%i,+'ic�CCe,,.4,,r 1Z`!\3 <br />My Commission Expires: <br />Notary Public <br />Wanda K. Trennepotd'—�` <br />Notary Public <br />State Of Colorado <br />Notary ID 19944001412 <br />MY Commission Expires FEB 26, 2018 <br />