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CFWrIFICATION <br /> u/� oh t LLe (print applicant/company name), <br /> The Appticant._ �� �� --- � <br /> b Liv. `v%e(`(print representative's name},as d�'�c����l;�'-�' _(print <br /> ?.... <br /> representative's title),does hereby certify thatr� o'"!�' ��'N 7 (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 ofth proposed affected area describrwi�I: ib .ot'the Reclamation <br /> Permit Application forC'© (operation name). <br /> File Number M-•77-SS <br /> T his form has been approved by rile Colorado iWined Lard Reclamation Board pursuant to its <br /> authority under the Colorado Lund Reclamation AG for 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 /> AtKN0WLEGED BY: • <br /> Representative c Name 1 r v <br /> `� �- L <br /> ,-applicant�_W 14 �� Or+ p <br /> f 'Vl <br /> Date <br /> "Title <br /> J <br /> STATE OF a ':r�i(is ) <br /> 1 )ss. <br /> COUNTY OF <br /> 7 oreeon)g was acknowledged before me this day of t,C. Z� b u� <br /> as her of "tZ <br /> My Commission Expires:--< - <br /> 1 Notary Public ���,t:=•Y•.Gd�i <br /> •� 1?r�nJ<► � <br /> r <br /> t )) L <br /> OF C0�,0 <br /> •:"r�siinrt �xrirEs <br />