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CERTIFICATION <br /> The Applicant, rn�l 11((Yf k C�C;c �cN1 j Pat;l(l'1 L1 (print applicant/company name), <br /> byI�OSMAM( . _(print representative's name), ans`(YY`n�trr 1, (punt <br /> representative's title), does hereby certify that�(JA on rsGn (structure owner) shall <br /> (` be compensated for any damage from the proposed mining operation to the above listed structure(s) <br /> is <br /> I' located on or within 200 (feet of the proposed affected area described within Exhibit A,of the Reclamation <br /> Permit Application for C'�C'u_�Q V ��� (operation name), <br /> r <br /> File Number M ( -9 l0 . <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 /> r ( AvnasAdv� <br /> Applicant�� pr rn II L&- °( `6lt d z �� Representative Name- <br /> Date_I -o�(-(_ Titled <br /> STATE OF D ) <br /> !' ) ss. <br /> COUNTY OF � OGY60n ) <br /> sr � n <br /> The foregoing was acknowledged before me thisdday of /vpuem ,20 h,,!6-Y-Lc�la <br /> ffl f)r(lto � as h �Qc,r�LYIIO�r1 of 1Y1'tnc�mlc��fk� u�-i < <br /> I <br /> --6 <br /> My Commission Expires: 1' <br /> Notaroublic <br /> 1 JILL MASTERS <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID S 19974010957 <br /> L <br /> COMMISSION EXPIRES DUNE 19,2017 <br /> 6 <br /> I <br /> I <br /> I <br />