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CERTIFICATION <br /> (print applicant/company an name),Applicant. 1 ZC <br /> by (print representative's natne),as ��� '' `� (print <br /> representative's title),does hereby certify that ✓ �+`>►'`�- structure owner Shall 9 ?I—l6 <br /> be compensated for any damage#tom the proposed mining operation to the above listed structure(s) <br /> located on or within 200 feet of th,proposed affected area described within li tbit A,of-the Reclamation <br /> Permit Application for--l/ l'© S !___ (operation name), <br /> File Number M-77-3�51 <br /> This form has been approved by the Colorado tbfinert Land Reclammtion Board pursuant to it} <br /> asithorhy under the Colorado Land Reclamation Act for the EWtraction oj'Construction Afaterials and <br /> the Colorado Mined Lund Reclamation Act for Hard Ruch,Afetal,and Desigttanal Mining Operations. <br /> Ant,alteration or modification to this form shall result in voiding;this form <br /> NOTARY FOR FR;ItMI T API'LECANT <br /> ACKNOWL-E;GED BY: <br /> ;lpplicant " �'�""" Representative Name <br /> Dare :__. - i to _._� Title <br /> STATE OF—__� '�' U <br /> } )ss. <br /> COUNTY OF ^ ) <br /> 1' ores=ar1g was acknoNvledged before me <br /> ._ this -- — 4LL�q by� <br /> 01 <br /> as ftY L �ei of . J <br /> t <br /> 1 <br /> My Commission Expires: C t •: �, <br /> p(p <br /> Notary Public aYUd� <br />