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CERTIFICATION <br /> The Applicant, Cheyenne County (print applicant/company name), <br /> by Marcy Brossman (print representative's name), as Administrator (print <br /> representative's title), does hereby certify that Patrick Anthony Jolly (structure owner) shall <br /> be compensated for any damage from the proposed mining operation to the above listed structures) <br /> located on or within 200 feet of the proposed affected area described within Exhibit A, of the Reclamation <br /> Permit Application for Jolly Pit#3 (operation name), <br /> File Number M- - <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 form shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> Applicant L'he�wyie. (hw4q Representative Name ' <br /> Date %-aR -l u Title <br /> STATE OF U(ieZ� ) <br /> ss. <br /> COUNTY OF ) <br /> The foregoing as acknowledged e ore me thi 4ay of , 20 , by <br /> <<Q... as of <br /> 67 <br /> My Commission Expires: <br /> N ary ublic <br /> VICKI mALN <br /> STATE F PUBLIC <br /> ICRpM1C0 2QOO24pI <br /> NOTA <br /> 27,21aO <br />