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CERTI MATION <br /> The Applicant. _....� �'vf `lr9h �LC (Print applicant/company name), <br /> representative's arne),as_, 1�, (Print <br /> / structure owner) <br /> shall 941-IG <br /> representative's title),does hereby certify that —7' ( )be compensated forany damage fromthe proposed mining operation to the. listed structure(s) <br /> located on or within 200 feet of th,proposed affected area described within F 'ltbit A.of the Reclamation <br /> ' QM�M � 4-MI <br /> Permit Application for�C'v•r'_�- _ ��" _ � (operation name), <br /> file tiumber N1-77-S',99 <br /> This form has been approved by the Colorado Mined Land Reclamation Board pursuant to he <br /> atrthorit v under the Colorado Laud Reclamation Act for the Extraction of Construction Materials and <br /> the Colorado Mined Laird Reclamation Act for Hart!Roch,Atetal,and Designated Mining Operations. <br /> Any alteration or nrodifrealion to this form shall result in voiding this form <br /> NOTARY FOR YF.11MIT APPLICANT <br /> ACKNOWL EGED BY: y <br /> ,kppiicant _ .Representative Name <br /> Date Title --- -n- '_------ ---— -- <br /> STATLOF <br /> l )ss. <br /> COUNTYOF <br /> t' i71'et!Qit1k was acknc'���'lcdged before me this day of U _ —. 20.'j by 1 <br /> Lt�<� as.,-JnYl w hey" of �� p_(`ffKalrLb,.. UY' <br /> My Commission Expires: - - <br /> Notary Public <br /> Y.f��?J'13�'encd•���' <br /> C6LO�P0 <br />