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a <br />CERTIFICATION <br />The Applicant, <br />/-ANSS uA) �ciNCAre fe ,—L.vc . (print applicant/company name), <br />by /till; (Ce L.gnr5 S-fo ,J (print representative's name), as r eSi o.(eN� (print <br />representative's title), does hereby certify that C,''�y e� �o rervc (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 4 GN, S-67,11 Gni c re fe_ (operation name), <br />File Number M X l9 z - 0 5.1. <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 />av q S fv.v � ..v c refe , yT c . <br />/3r:Applicant <br />Date <br />e_br(oAry 1) 20!/ <br />Representative Name /'� r LarwS SI oA) <br />Title U (el ( of e4/1-- <br />STATE <br />4vf <br />STATE OF Co(orc o ) <br />) ss. <br />COUNTY OF cr) <br />The foregoing was acknowledged before me this I if day of Q7_ rtw e. r , 20 (4 , by <br />fr ke 4cvv)S-Ea i as n res r'd e,vr of ,%�.,vS Stow Cc�,vcr c'f , .L.vc. <br />U <br />Nota <br />Public <br />My Commission Expires: C t.`-4 <br />ANDREA WEBB <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />NOTARY ID 20124070532 <br />MYCOMMISSION EXPIRES DECEMBER 14, 2016 <br />