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9 <br /> ti <br /> CKRTIF ICATION <br /> The applicant.` �� ��LGG (print applicant/company name), <br /> y--,,,)jv-< (print representative's name)),as _(?/�'�, (print <br /> representative's title),does hereby certify that 4:- T7 u- L1'^k_{structure owner}shall 9Op <br /> It <br /> be compensated for any damage tiom the proposed mining operation to the above listed structure(s) <br /> located on or within 200 feet <br /> �of th-proposed atfiected area described within I: ibit A.of the Reclamation <br /> Permit Application for �'v J" C '�"�0i � _ _ � (operation name). <br /> Idle Number M-7T- F-W <br /> This form has been approved by the Colorado Afined Land Reclamation Board pursaant to its <br /> authority under the Colorado Land Reclamation Act for the Extraction of Construction Haterials uad <br /> the Colorado Mineil Land Reclamation Act for Hartl Rock,Aletal,and Designuted Alining Operaliona. <br /> Any alteration or rtrodifrcation to th&./orm shall result in voiding thin form <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNC)VVL GED BY: <br /> ;applicant �!" ~ � RepresentativeNamc t' '_LL�� i�;t%v�c-r <br /> Date <br /> STATE OF <br /> COUNTY OF <br /> ) arepai t was acknowledged before me this/day of 20 b. <br /> My Commission l,xpires: <br /> Notary Public PRY P <br /> l - fi�e.ncla �n <br /> t` �F Cat�ci,P <br />