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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 Margaret R Bloder Trust (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 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 C, ie Jenne Representative Name ` %1-Cu 9aI5*'l W <br /> Date Title C31Mial �� <br /> f�-� r <br /> STATE OF ) <br /> ss. <br /> COUNTY OF ) <br /> The foregoin was acknowledged before me thi day of , 20/ , by <br /> LAU .� as of <br /> A�— <br /> c My Commission Expires: lj2 <br /> Noftary Public <br /> VICjRhy <br /> KI� *q�N <br /> sr�p�PC <br /> My COAM 1�4002OR <br /> ° sawirn, 8 <br />