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CERTIFICATION <br /> The Applicant, (� CCf YM tc�< �� U `ccon d �crrl 1,U (print applicant/company name), <br /> (print representative's name), as &-C',11,41) L n n YYvo (print <br /> representative's title), does hereby certify that Lp�3�A- �pC (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 := �-o . . r) A �� � (operation name), <br /> File Number Mloj-(o 10. <br /> t This.form has been approved by the Colorado Mined Land Reclamation Board ptrrsuant 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: l <br /> Applicant��� c Qu14 �`l�QU �C Representative Name- 0-S M rrn a e K <br /> Date 11 -a 1 - 1(o Title rY1an a-g rLa rn Cs'y1 Lp /i <br /> STATE OF( �LCro c-) ) <br /> ss. <br /> COUNTY O , iJor) ) <br /> Si <br /> The foregoing was acknowledged before me this j 1 day of �u_11UkL-0- ,20� by <br /> .�(!m� s CYI 't('nrm�QL as ' R(�r acv,,o�1�� of rI1gegrtl,�t�[C�JCC0.uo a�� !'c��✓ 1 �.0 <br /> e <br /> My Comm' -fission Expires: �-� `� <br /> Notary b is <br /> JILL MASTERS <br /> NOTARY PUBLIC <br /> STATE OFCOLORADO <br /> NOTARY ID# 19974010957 <br /> MY COMMISSION EXPIRES JUNE 19,2017 <br />