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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 he 4ennLO. Representative Name cio5*010, <br /> Date $-��-I(_p Title 0(tb /1j 5�r <br /> STATE OF ) <br /> ss. <br /> COUNTY OF ) <br /> The foregoing was acknowledged before me this day of , 20 O,by <br /> as of <br /> f <br /> t My Commission Expires: 7�d <br /> IAL— <br /> N(fary—Public <br /> VICK$MALLN <br /> STATE OF c�� <br /> MY C0�NOTARY�D 200��R� <br /> B=27,2011 <br />