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CERTIFICATION <br />The Applicant. Parkerson Construction, Inc (print applicant/company name]. <br />by Alan Parkerson (print representative's name). as Vice President (print <br />representative's title), does hereby certify that >E. (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 C Road Pit <br />File Number M - <br />(operation name), <br />This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its <br />authority under the Colorado Land Reclamation Art fur the Extraction of Construction Materials and <br />the Colorado Mined Land Reclamation Act for Hard Rock, Afetal, and Designated Alining Operations. <br />Any alteration or modification to this form shall result in voiding this form, <br />1041KIZ'711111■xntaU3iI'm Ir11"WUa16yW1 N <br />ACKNOWLBY: ' <br />Appl ican' �� Representative Name r �� <br />Date Ci Title <br />STATE OF C� } <br />} ss. <br />COUNTY OF kl e Q & ) <br />The foregoing was acknowledged before me this ('1��� day of � fl ,rah ,', 20 ! to, by <br />�e,wi, S Htk r7SOvl as of n i[. L_• C ,owl <br />at,ti. lvfy Commission Expires: 3 !� <br />NotaryPublic Ob <br />LAURA L HARTMAN <br />Notary Public <br />State of Colorado <br />Notary 10 19994021447 <br />My Commission Expires Aug 3, 2019 <br />