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CERTIFICATION <br /> The Applicant, J Goj 7- _ aty&rtr (print applicant/company name), <br /> by xc x- 4 e Ar (print representative's name), as 0. (print <br /> representative's title), does hereby certify that5aa, r? -r f . (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 7`lro -Ce-VEemk-R; __ (operation name), <br /> File Number M- - . <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 far Harr!Rock,Metal, and Designated Mining Operations. <br /> Any alteration or modification to this form shall result in voiding this fornh. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> Applicant #ew 2.- -0u,ft zs, Representative Name rj?-�c( <br /> Date j' �iZZ/d Title C'a.t,^+•�` i"cF Pr <br /> STATE OF <br /> ss. <br /> COUNTY OF � } <br /> T e foregoing was acknowledgede me this1lay of 20 by <br /> t �ri as MI C'M0.in of <br /> `k- U a. r 0 M M <br /> My Commission Expires: 1,5(61 <br /> Notary Public <br /> TOBE A.WRIGHT <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 19974003957 <br /> MY COMMISSION EXPIRES 0312912017 <br />