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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 /> (pr <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 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 ill voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> Applicant Che A tie On, { _ Representative Name p y� <br /> Date Title Ohl i t i ail�-�-rc�fbr <br /> STATE OF fQCGfJ ) <br /> ss. <br /> COUNTY OF & l , ) <br /> The foregoing ti as acknowledged e ore me thi ay of , 20 , by <br /> as of �r <br /> L <br /> My Commission Expires: <Y <br /> N ary ublic <br /> VICKI yqL <br /> EN <br /> STATE OF CPUBLIC <br /> NO OLR Aj)co 2O 00732E <br /> 2018M � <br />