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RF,^ "IED <br /> MAY 2 0 2016 <br /> CERTIFICATION DIVISION OF RECLAMATION <br /> MINING AND SAFETY <br /> The Applicant, J ,j.1 7` &-wt rr (print applicant/company name), <br /> by ,g-ICZ-i La m (print representative's name), as el {print <br /> representative's title), does hereby certify thatJ1,12 Y7461-AW, -w (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 forT_ 7'}a w-ee-im (operation name), <br /> File Number M-Ly- . <br /> Thisform 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 jge r t 4'm& 2��, Representative Name J� <br /> Date /Z "/d Title C'o,ty.�•�r`ssr'e�N <br /> STATE OF C0 ) <br /> )55. <br /> COUNTY OF ) <br /> T e foregoing was acknowledged b fore me thisl ay of,M� 20 by <br /> t�Yt as M o f <br /> My Commission Expires: 3Ya 5017 <br /> Notary Public <br /> TOBE A.WRIGHT <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 19974003957 <br /> MY COMMISSION EXPIRES 0312912017 <br />