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CERTIFICATION <br />The Applicant, STOMP L►/l90tsS'l5.Lt% /)1(', (print applicant/company name), <br />by 31 nk S-ry , 1t.G.vti1 (print representative's name), as PRc S 1 Dam- (print <br />representative's title), does hereby certify that F'Ot.) V/}LLEy CAVA' (structure owner) shall <br />W/ CC,X(yc <br />be compensated for any damage from the proposed mining operation to the above listed structure(s5 <br />located on or within 200 feet of the proposed affected area described within Exhibit A, of the Reclamation <br />Permit Application for B RZ Wi i S TI2AJE Q cm pR y (operation name), <br />File Number M-) 597 <br />Damages to include necessary repairs to the Poudre Valley Canal together with the value <br />of any lost water. <br />This fora: 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 STDij i kJ, DLL V)w, JAM!, Representative Na /; { �� .i , .LAl.-C-p)c/ <br />Date 7- e • J:S- <br />STATE OF COVeCG(i-r' ) <br />) ss. <br />COUNTY OF Ck.r-tilli.ere) <br />The foregoing was acknowledged before me this SS day of Jam, , 20 1 by <br />� M `StYtG�9Ou3 as ?C -c' Cott—LI— of 3{znc i �Jhal 1� trl . <br />Title <br />A FA9f tion <br />Notary Public <br />My Commission Expires: Mak 3(r J Il % <br />AMY E LINCOLN <br />NOTARYPUBLIC . STATE OF COLORADO <br />NOTARY ID 20054021488 <br />MY COMMISSION EXPIRES MAY 31,2017 <br />