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CERTIFICATION <br /> The Applicant, �� C�,� << ` _(print a licant/com an name), <br /> n <br /> .,_Zr (print representative's name), as <br /> representative's title does hereby certify that �71a.0 k �.l,_���_jEn_e, ____(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 pro osed affected area described within Exhibit A, of the Reclamation <br /> Permit Application for (operation name <br /> File Number M-i�19Z- o5'i <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: ,,n <br /> Applicant `� Y� Representative Name ,r 1 '�( <br /> Date �' Title l[St•n �� s)en to" � Vic, <br /> STATE OF ) <br /> ss. <br /> COUNTY OF <br /> The foregoing was acknowledged before me this day of 20 l Ca by l <br /> of <br /> My Commission Expires: C/ <br /> Po <br /> of ry ublic <br /> [ MISTY MARIE BETHEL <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20154014034Y COMMISSION EXPIRES APRN 8,2019 <br />