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CERTIFICATION <br /> The Applicant, (print applicant/company name), <br /> by (print representative's name), as Senior Vice President (print <br /> representative's title), does hereby certify that (stricture owner) shall <br /> be compensated for any damage from the proposed mining operation to the above listed stricture(s) <br /> located on or within 200 feet of the proposed affected area described within Exhibit A, of the Reclamation <br /> Permit Application for Ard Property Borrow (operation name), <br /> File Number M- - <br /> This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its <br /> authority tinder the Colorado Land Reclamation Act for the Ex1D * <br /> uction Materials and <br /> the Colorado Mined Land Reclamation Act for Hard Rock,Med Mining Operations. <br /> Any alteration or modification to thisform shall result in voidiNOTARY FOR PERMIT APP <br /> ACKNOWLEGED BY: <br /> Applicant Rep sentative Name <br /> Date itle <br /> STATE OF ) <br /> ss. <br /> COUNTY OF ) <br /> The foregoing was acknowled before me this day of , 20_, by <br /> s of <br /> My Commission Expires: <br /> Notary Public <br />