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CERTIFICATION <br /> The AAA fan (print applicandcompany name), <br /> by T1.i.,([1c cz- <br /> ry _(print representative name),as u s (print <br /> representative's title), does hereby certify that /+ a (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 (operation name), <br /> File Number M9,367- <br /> Thls form has been approved by the Colorado Mined,Land Reclamation Board pursuant to its <br /> authnritu unflpr rt.o 7.....4 !__ . .-... - l'a----- .,n....rs <br /> Airy alteration or modification to rats form shall result in volding this form. <br /> NOTARY FOR RMIT APUTCANT <br /> ACKNOWLEGED BY: <br /> Applicant /I lepresentative Nam e14 <br /> 41 � h <br /> Date ] Title .." <br /> STATE OF o ) <br /> )ss. <br /> COUNTY OF 6� ) <br /> The foregoing was acknowledge4before me this G day of J u rY ,20(L, by <br /> of <br /> /AUIUL 4 X My Commission Expires: 4�� <br /> Notary Public <br /> MARTHA S.UIUOM <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20064MI14 <br /> Received Time Jul. 6. 2016 10 . 34AM No• 0094 <br />