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CERTIFICATION <br />The Applicant, 1d tel e --bb N gq, f t''qc.� (print applicant/company name), <br />by (Zoyeit t r (print representative's name), as vt,.N.� (print <br />representative's title), does hereby certify that yakbpaIv. of Assn. (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 Cn OC9 n (operation name), <br />File Number M-ffl - 441. <br />This form has been approved by the Colorado Mined Land Reclamation Hoard 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 `I Representative Name 9/ / 7 / „�►0,i& s � <br />Date — / — Title O ,..oru2, <br />STATE OF o OV ' . O ) <br />) ss. <br />COUNTY OF atar-r (t ) <br />TM foreg�ooing,was acknowledged before me this3 day of ;' b.Q// , 20) S ,iby <br />09ZV onOr1Pi as M.-n/12X of D r--f-m. i k.9q 1/.f 900 e S <br />A -Lt._ fn. elV.�- 4--ilbly Commission Expires: 0-7/08)a° i -i <br />NQJ <br />Public (J <br />ASHLEY NOPRY GREEN <br />PUBLIC <br />STATE OF COLORADO <br />NOTARY ID 120004022648 <br />Commission Expires July 8, 2017 <br />