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CERTIFICATION <br /> The Applicant � LLX— (print applicant/company name), <br /> by fZrZW. Ij ta hiatA.{print represent ive's name),as tM,tALk,e�o l' (print <br /> representative's title),does hereby certify that bay . (structure owner) shall <br /> be compensated for any damage from the proposed mining operation to the above Iisted 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 \J4.t..C..V�S ('..&4p t C•t�-�. f Csr ?-r" (operation name), <br /> File Number M-22_-,f5!.1 <br /> This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its <br /> authority under the Colorado Land Reclamation Act for file 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: Q f 1 <br /> Appiican d'1�'Dr PeCre&11 o*I•IC epresentative Name P il't U" n a <br /> Date � Me' <br /> Title me-mbz <br /> STATE OF ^)) <br /> )ss. <br /> COUNTY OFjj-,M —f ) <br /> The fore irng was acknowledged before me this day of ,20 by MLI <br /> asof �tC. <br /> `7A_,,_kj./ � My Commission Expires: <br /> Notary Public <br /> o,�pi1Y Pug <br /> Brenda <br /> K. <br /> Barker <br /> 9��F C0�0�! <br /> Commission expires <br />