Laserfiche WebLink
CERTIFICATION <br /> The Applicant. (print applicant company name). <br /> by (print representative's name).as Owner (print <br /> representative's title).does hereby certify that (structure owner)shall <br /> be compensated for any damage from die proposed mining operation to the above listed structure(s) <br /> located on or within 200 feet of the proposed affected area described within Exhibit A.of the Reclamation <br /> Permit Application for Westhoff Pit (operation name). <br /> File Number M-1977- <br /> This form has been approved bt'the Colorado dined Land Reclamation Board pursuant to its <br /> authoriy under the Colorado Land Reclamation Act for the Extraction of Construction Materials and <br /> the Colorado.lfined Land Reclamation Act for Hard Rock,:â–ºfetal,and Designated;Mining Operations. <br /> Anv alteration or modification to this form shall result in roiding this form. <br /> NOTARY FOR PER.NHT APPLICANT <br /> ACKNOWLEGED BY: <br /> Applicant Representative Name <br /> Date Title <br /> STATE OF ) <br /> ss. <br /> COUNTY OF ) <br /> The foregoing-was acknowledged before me this day of .20_.by <br /> as of <br /> My Commission Expires: <br /> Notary Public <br /> 20 <br />