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CERTIFICATION <br /> The Applicant ! t?4L::!yj (print applicant/company name), <br /> by r�r„ _ i wn���L.{print represent ive's name),as tNttAkkd4r�lL (print <br /> representative's title),does hereby certify that V (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 \JAc.0 S (' " Lt`r-y sz-- f�� (operation name), <br /> File Number M-22 _-ff 17 <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:Applican3t�&Y'�/ &CHCMUC&AI Representative Name scyt L►' nay-- <br /> Date Me Title M&YL 64K <br /> STATE OF �) <br /> )ss. <br /> COUNTY OF ) <br /> The fore> ing was acknowledged before Mesthis day of ,20 by <br /> as-J�� Y-�y of LZC. <br /> My Commission Expires: <br /> Notary Public <br /> a�tpRY FUB� <br /> Brenda <br /> K. <br /> Barker o <br /> commission expires <br />