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CERTIFICATION <br />The Applicant, (�5 L LC <br />by . An STA /CrGGtW _(print representative's name), as <br />representative's title), does hereby certify that C AOT - <br />be compensated for any damage from the proposed mining operation <br />located on or within 200 feet of the proposed affected area described <br />Permit Application for <br />File Number M-) 92- E45: - <br />(print applicant/company name), <br />(print <br />1BRawNsrQ f, (1)v4kky <br />i' 7 (structure owner) shall <br />to the above listed structure(s) <br />within Exhibit A, of the Reclamation <br />(operation narne), <br />This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its <br />authority under the Colorado Land Reclamation Adler 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 <br />Date. _ y .. Title <br />STATE OF t ; It - l'[" r l(: ) <br />} ss. <br />COUNTY OF LC c }E_c ) <br />The foregoing was acknowledged before me this P = da} of __ <br />°20 !'". '> by <br />NOTARY FOR PERMIT APPLICANT <br />Representative Name _ <br />f t "l t Y <br />Nbtary Public <br />My Commission Expires: <br />;ELF <br />T3L1D <br />Cr; C.O ORM.DO <br />7.0 ,u .:2x35 <br />_� rL <br />