Laserfiche WebLink
CERTIFICATION <br />The Applicant, C40I.00cLclo Inti!) (print applicant/company name), <br />by M:kQcfM (print representative's name), as �.nlZ (print <br />►'�i��-i c.. scue_. <br />representative's title), does hereby certify that v -F 4CvC.ol2."o (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 -W&5 -HI <br />c4a 1" 4 um.� N>o M:c%e-j6. <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 PERMIT APPLICANT <br />ACKNOWLEGED BY: / <br />Applicant(:�O- �!� s Representative Nam <br />Date /,� Title <br />STATE OF Co(, ) <br />) ss. <br />COUNTY OF & ld-Qj� ) <br />The foregoing was acknowledged before me this (3 day of , 20j5, by <br />trind"�. �2ur ter « � x �,� MQntit�t1_ of �t !CKccto IV1i (,n� C� <br />My Commission Expires: 136 d -O 18 <br />Notary Publk <br />MEGAN G FREYSCHLAG <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />NOTARY ID 20144025710 <br />MY COMMISSION EXPIRES JUNE 30, 2018 <br />