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CERTIFICATION <br /> r <br /> The Applicant, L (print applicant/company name), <br /> by )A� (print representative's name), as m O (print <br /> representative's title), does hereby certify that f--O C-e5 CYO (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 the proposed affected are described within Exhibit A, of the Reclamation <br /> Permit Application for (3 m C9�Z�IhL �^ (operation name), <br /> File Number 1bYrT�3 '-���� d Z f <br /> This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its <br /> authority under the Colorado Land Reclamation Actfor the Extraction of Construction Materials and <br /> the Colorado Mined Land Reclamation Act for Hard Rock, Metal, and Designated Mining Operations. <br /> Any alteration or modification to this form shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> Applicant &Lj� presentative Name v <br /> Date (9 A 7 Title <br /> STATE OFCplpr, p ) <br /> ss. <br /> COUNTY OFT ,� ) <br /> he foregoing was acknowledged before me this-^ay of ql , 2011, by <br /> 11 PGu%.%71-ee as D�e,ra-tbr of AGL Cam ' S <br /> My Commission Expires: (] — - Qkl� � <br /> otary Public <br /> __4soa'e��aVna®3�s�a�dxe NoissiwwoaAw <br /> 94900MOZ Al A VlON <br /> OOV210100 d0 31V1S <br /> 0118f1d A2lb'lON <br /> NNV0 0W NW <br />