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CERTIFICATION <br />The Applicant, L,TS L L ( (print applicant/company name), <br />by T lvlr 1� 1 C �� y,1 (print representative's name), as 'f z ),DE'i (print <br />representative's title), does hereby certify that wpj;,v, s;; rYc y 5 WI kT (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 8, cam' ki,usnivte 6-,i,2 /1,k)/ (operation name), <br />File Number M- - `�"3-1'• <br />410147-°'' <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 L J S LLL Representative Na e <br />Date 1) - z 3 -ZUNIS Title Pic,gs "Id ` .4/ <br />STATE OF COtbrocka <br />COUNTY OFLUY'1nler <br />) ss. <br />:STIi'1C- -1211/ <br />The foregoing was acknowledged before me this] day ofem , 20`5, by <br />j-kaTer Tiede. no\—o 'C -l1 of wac}cl Suety D <br />Notary Public <br />My Commission Expires: \212 Jzori <br />