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CI,hTII;ICATION <br /> The Applicant. ^-'" �� �®`.� PLC (print appiicantleompany name), <br /> by •.dk,e-y-(print representative's parne),as_._1,_,,.I.I: (print <br /> representative's title).does hereby certify that owner)shall 94 -t G <br /> be compensated for any damage from the proposed mining operation to the above listed structure(s) <br /> located on or within 200 fee�),X, <br /> fproposed affected area described within I: ibiitt A.of the Reclamation <br /> CM�M �r11 /Permit Application for T � _ _ ��' � � (operation name). <br /> File Number h1-7T-fS-Jrl <br /> This form has been approved by the Colorado A iced Land Reclamation Board pursuant to its <br /> authority under the Colorado Land Reclamation;icifor the Extraction of Construction Alaterials and <br /> the Colorado Nfined Land Reclamation Act for Hard Ruch,Aferal,and Designated Alining Operalions. <br /> Any alteration or modification to W9 form shall result in voiding rhis form <br /> NOTARY FOR PERMIT APPLICANT <br /> AC'KNOWLWED BY: <br /> "tea r"s c�v f�l/ d►gRepresentative <br /> Applicant.�_-_- Namc -- <br /> Data _ _ %% Title <br /> 1 1 ss. <br /> COUNTY OF <br /> I' e�rectou Q Was aerknt���lcdped benf�olre me tltis dap of LLU _ •20 j by <br /> as....1 t!�' ��c• of._ - � al��,H (�.. <br /> � C <br /> My Commission Expires:--!� <br /> Notary Public y���pRY ptj <br /> ={j L3r-enda �� <br />