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CERTIFICATION <br /> The Applicant, K (T C Aabd ty C.r, i j A a`/ (print applicant/company name), <br /> by No If 0 4 TlvW6 (print representative's name), as RO < < (print <br /> representative's title), does hereby certify that 4 A PP Y (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 C AK SD N C 6, v N ? Y (operation name), <br /> File Number M-c T)( <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: Z,--4 -/ 9 <br /> Applicant 11, I C SeAj C 1 jy Representative Name 10 MA//,N.6 <br /> Date 3- 1 — 1 Title 60 c L K 17 e-I�f,sc+N C-0/-, N T <br /> STATE OF C���,��,,�c ) PA' <br /> ss. V <br /> . s , <br /> COUNTY OF. NO , j271 9 <br /> MY COMMi. ', S AUG.20,2016 <br /> The foregoing�w�'`as acknowledged before me _c <br /> is ay of , 20 ,by <br /> C�-1�''(, � I �y— as (�jVh M SS ILM. L� of i t-- �cc <br /> ir <br /> ,L My Commission Expires: lug Pu is <br /> PAULA S.WEEKS <br /> NOTARY PUBLIC <br /> STAVE OF COLORADO <br /> NOTARY ID 20084027129 <br /> MY COMMISSION EXPIRES AUG.20,2016 <br />