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CERTIF ICAno.N, <br /> cpwt L L c' • <br /> I'he Applicant. _—, 14 , (print applicant/company name), <br /> by t' -:rl,,..=;(print representative's name),as,_. I/;,�,.`.�;•'.�`` (print <br /> s representative' title),does hereby certify that_4 '� 7L�- L �^k_-{structure owner)shall �y <br /> be compensated for any damage trom the proposed minims operation to the above listed structure(s) <br /> located on or within 200 feet,of th proposed attected area described within k • ibis A.of the Reclamation <br /> Permit application for L'v S �,n.. (operation name). <br /> File Number M- 77-30 <br /> This form has been approved by.rile Colorado Mined Land Reclanwtion Board ptustiant to fts <br /> authority under the Colorado Land Reclamation Act for the Extraction of Construction Materials and <br /> the Colorado Afined Lund Reclamation Acifor Hard Rock,Metal,and Designated Minitrg Operations. <br /> Any alteration or modification to th&form shall result in voiding this fornL <br /> NOTARY FOR I'VI IIT AI'I'LIC:ANT <br /> ACK1`OWLEGE'D BY: <br /> Applicant -�"'� ` ��'r`r'"'y^ RepresentativeNamc <br /> D3IC _. _:...F_j_ i Co title _ _ -- -- - --- <br /> STATE OF u } <br /> 1 ss. <br /> COUNTY OF <br /> 1' nreszon}t;%vas ackno vledged before me this f�day of (,��� - ' 20� h} <br /> y 1 eX 3s._.LY�Pn � _of.. �� tau t.t� <br /> r� r <br /> 1 t <br /> � ���� My Commission F�xpires:--i�.;� �Y G <br /> Notary Public <br /> pU� <br /> . =t ate',•.' _,`- li <br /> s �.rr•,•��� _xrfrr <br />