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CERTIFICATION <br />The Applicant, Collins -Morehead LLC (print applicant/company name), <br />by Daniel L. Collins (print representative's name), as Manager (print <br />representative's title), does hereby certify that Collins -Morehead LLC (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 Limited Liability Partnership (operation name), <br />File Number M- 1986 102 <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 />ACKNOWLEGED BY: <br />Applicant Collins -Morehead LLC <br />Date <br />NOTARY FOR PERMIT APPLICANT <br />STATE OF ( <br />) ss. <br />COUNTY OF <br />Representative Name Daniel L. Collins <br />Title Managing Partner <br />The foregoing was acknowledged before me this ; day of . <br />of <br />Notary Public <br />My Commission Expires: <br />PAT; .'Di?t DASARO <br />i NOTARY PUEcdLUC <br />1 P.TTATi OF COLORADO <br />f No i 4;RY ID 20;:04003856 <br />I.- CC`? ;",i SS:O _EXPIRES 02/14/2017 <br />