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O�q 4-<<3 <br /> CERTIFICATION <br /> San Miguel County Colorado <br /> The Applicant, (print applicant(company name), <br /> by Lynn Black � (print representative's name),as Country Adminit�r (print <br /> representative's title), does hereby certify that i,c Service-0.. Rf_Col ora4ttructure 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 Pathfinder Pit (operation name), <br /> File Number M- 1994 113 <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 forin shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: ~ j� ----- <br /> Applicant San Miguel County, CO. Representative Name Lynn Black <br /> Date 10/5/2016 Title County Administrator <br /> STATE OF rolorado ) <br /> )ss. <br /> COUNTY OFSan Miguel ) <br /> T�y foregoing was acknowledged before me this 5 day of bdoQer ,20/6,by <br /> (:A t�rr2 ct'1 �t/a r e 1 d as �h e f' pepu of Oao m t- et CO Lc n <br /> CD»tin�i5st rs <br /> My Commission Expires:_ <br /> otary Public <br /> Acknowledgement incorrect. <br /> Should list"Acknowledged by Lynn Black" <br /> Not notary's name. <br /> Please have notary Carmen Lynn Warfield <br /> correct and initial, and return to the Division. <br /> 3 <br />