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CFRTIFICAnON <br /> The Applicant.� u�� ("rint+applicant/company name), <br /> LIOAq vtizf'(print representative's name).as (print <br /> representative's title) does hereby certify that__E e e.N (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 till proposed affected area described within 1. A ibit A.of the Reclamation <br /> ' QM�M � f.�M ! <br /> Permit Application for e'© .�" � ! _ � it(operation name). <br /> File Number M-77-31Y <br /> This form has been approved by the Colorado Mined Lard Reclamation Board pursuant to its <br /> authority under the Colorado Land Reclamation Act for the Extraction of Co»structivn Afaterials and <br /> the Colorado Mined Land Reclamation Act for Hard Rock,Metal,and Designated Mining Operations. <br /> A►g alteration or modifreation to this form.shall result in voiding this fornL <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> L <br /> r _ <br /> Applicant H � �""" Representative Name 5 � i��1��I' <br /> ti E' <br /> lr- <br /> Date - ) - %5 "Title <br /> STATE Of <br /> 1 ss. <br /> COU'\'rY OF���c ,.,t ) <br /> 7' bregeon g was acknowledged before me this day(if .11tj 20_UL by <br /> as M.Ona_b-ey- <br /> My Commission Expires:�' <br /> INRY P& <br /> Not ary Public <br /> t?renda <br /> `r�FOF`COLQ�Q4 <br />