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CERTIFICATION <br /> The Applicant, _ cis id 9- awe 0,-,,,,,r.w-rs.5z,) (print applicant,company name). <br /> by C.E-4- Cq^) (print representative's name), as (0('6P`AT02 _(print <br /> representative's title),does hereby certify that Sum r KgTN, 6.,,RA0 (structure owner)shall <br /> be compensated for any damage from the proposed mining operation to the above listed stnicture(s) <br /> located on or within 200 feet of the proposed affected area described within Exhibit A.of the Reclamation <br /> Permit Application for Martin Pit 1-A _(operation name), <br /> File Number M- 1990- 110 <br /> This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its <br /> authority under the Colorado Land Reclamation Act fir the Extraction of Construction Materials and <br /> the Colorado Mined Land Reclamation Act fir Hard Rock, Metal, and Designated Mining Operations. <br /> Any alteration or modification to this firm shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED B • <br /> - p &EAApplicant 1 , Ke resentative Namc � ri <br /> Date S 13-/E Title OpC.(L A T'4),.. —STATE OF C pV r ) <br /> ) ss. <br /> COUNTY OF - i ) <br /> -The foregoing was acknowledged before me this23 day oft ;20\(, by n <br /> • My Commission Expires: b-A 1Zc'i 1 \Z <br /> Notary Public <br /> LORI GOWDY <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID#20054029870 <br /> My Commission Ex• es July 29,2017 <br />