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CERTIFICATION <br />The Applicant, Western Slope Materials LLC, by Sean Mello, as General Manager, does <br />hereby certify that _ (structure owner) shall be <br />compensated for any damage from the proposed mining operation to the above listed <br />structure(s) located on or within 200 feet of the proposed affected area described within <br />Exhibit A, of the Reclamation Permit Application for Blue Pit, File Number M-1 981-207. <br />This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its authority <br />under the Colorado Land Reclamation Act for the Extraction of Construction Materials and the Colorado <br />Mined Land Reclamation Act for Hard Rock, Metal, and Designated Mining Operations, Any alteration or <br />modification to this form shall result in voiding this form. <br />ACKNOWLEGED BY: <br />W'E'% ►.� <br />Applicant <br />Date I t 1 t ht'.' <br />NOTARY FOR PERMIT APPLICANT <br />epresentative Name _ Saat-S <br />M jr- L. `J <br />Title 67Za1Z.4,a� �`t a,,A,1.c,ti— <br />STATE OF if jV 4g } TIMOTHY OLlC <br />)ss. Notary Public <br />COUNTY OF r�iG State o4 Colorado <br />!Votary ID k 20164038406 <br />commission Expires 10 06 2020 <br />The foregoing was acknowledged before me this I day of Novw-,bar , 20 1%, by <br />as & r to r ti.. - WtAq�-..co f W e, s 1 t r S L4 A er v—,x, r%e L %r4 L s 't- &- c - <br />r~ _ My Commission Expires: f�c LZ' Public <br />