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CERTIFICATION <br /> The Applicant, Western Slope Materials LLC, by Sean Mello,as General Manager,does <br /> hereby certify that L_` T� : =t ,.:K (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-1981-207. <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 /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> Applicant h`� Representative Name < A WA or t.`D <br /> Date f 11 1 -Title `r <^.. tz k. wt ►. -r'' � '--` <br /> STATE OF tsMC.,TN.Y 0LK <br /> ] SS. N'. !Sty Punlie <br /> at <br /> COUNTY OF s tl .#! �; <br /> �uta .� 1ttH40ttA,t <br /> t,rtvtv,sn.m±ix..yr,�•. Cy e� Ui ZU1,J <br /> The foregoing was acknowledged before me this ! day of No vep.6c,- ,20 11, by <br /> � �7 c LIc as <br /> t..J �srteti <br /> c��- -'",,�(� ••• l/ My Commission Expires: 1���40 <br /> Notary Public <br />