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CERTIFICATION <br /> The Applicant, (` I T C (-s N C L u fi j � (print applicant/company name), <br /> by bit-V 1 () 1fD 4 NO.4/6 (print representative's name), as ( O f_ (print <br /> representative's title), does hereby certify that j APP Y CRC EK ) NL.. (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 V- 1 / C A� $o N C U L/ A/ 7 _(operation name), <br /> File Number M4V- <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 (< I I c i1 P-s e lV c o v NT Y Representative Name O 4-' 0 L. 11 1.14NtiA/6 <br /> Date 3- 1 - l‘ Title 6c) cL K 17- c fri:st,v tv v Al T )' <br /> STATE OF eviuyetdc ) P�, <br /> Kt ) ss. N <br /> COUNTY OF , ( ) NC . <br /> MY COMM! • AUG.20,2016 <br /> The foregoing was acknowledged before me this i day of 4.1 , 20 / , by <br /> 0(L(4 1 . 1(11141E.' as vhrkiiSSItYL w of ) I &Lar'Stra Co <br /> ( 42frI*/ -1/11 My Commission Expires: , 0-7)/) 26/(„, <br /> Pu• lc <br /> PAULA S.WEEKS <br /> NOTARY PUBLIC <br /> STA' <br /> NOI/Ak`; ID 2u084027129 <br /> MY COMMISSION EXPIRES AUG.20,2016 <br />