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CERTIFICATION <br /> The Applicant, C r t Sc i� a c A G<- -te\ -tY L. (print applicant/company name), <br /> Cnc�o r (print representative's name), as President (print <br /> representative's title), does hereby certify that (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 C y (-� Sclf\6 0.r<\ (' col�IQ k -I (operation name), <br /> File Number M- 2007 058 <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 Representative Name E,hq ��( (lyr7Hs&I <br /> Date Title /�/'C-S <br /> STATE OF ) <br /> ss. <br /> COUNTY OFZ�arjTn ) <br /> Tye foregoing wa acknowledged re me thi�g-day of <br /> My Commission Expires: �//X/j <br /> Notary Public T— <br /> ALETHEA FOSTER <br /> Notary Public <br /> Carbon County <br /> Wyoming <br /> q "y Commission Expires Jun 18,2018 <br />