Laserfiche WebLink
CERTIFICATION <br />The Applicant, (_ b\) C\t \(\ (7 t (print applicant/company name), <br />by ; fir, �-�R �� (� �� •� :� �, print representative's name), as (; e =; , ,e <br />(print <br />representative's title), does hereby certify that ('\\ aC cCcurkkj,C01a-aa0 igructure 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 C e-, Q C-1(0Lc( + . c_ (operation name), <br />File Number M- zc; - <br />This form has been approved by the Colorado Mined Land Reclamation Board pursuant t its <br />authority under the Colorado Land Reclamation Act for the Extraction of Construction Materi and <br />the Colorado Mined Land Reclamation Act for Hard Rock, Metal, and Designated Mining Op Inions. <br />Any alteration or modification to this form shall result in voiding this form. <br />NOTARY FOR PERMIT APPLICANT <br />ACKNOWLEGED BY: <br />Applicant C-4- F) cvi. CA- c,,, In.Representative Name <br />Date t2/qtr <br />STATE OF 1 ' 10)LLI � ) <br />) ss. <br />COUNTY OF ( Cu-brp ) <br />Tlike foregoihs was acknowledgedefore me this <br />l 61J/tih as 1-a i-kasii c\FN r <br />Title- (Cc- 6 <br />day of / pi: iY11 ' , 20k , by) <br />of C f'j Wt\ //N RO(FL.I'JC <br />My Commission Expires: 4l0 <br />ALETHEA FOSTER <br />Notary Public <br />Carbon County <br />Wyoming <br />My Commission Expires Jun 18, 2018 <br />1"NW -IN, 411 <br />Notary Public <br />