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CERTI)r ICA.'i•ION <br /> ..`.-bu rint aItcant/com an y name <br /> The Applicant. _ __ �� _ (p PP P ) ), <br /> by ` t "v _ j t,••{i{v•�i'(print representative's natne),as____t,.L,,�i.i;r-.," -- (print <br /> representative's title),does hereby certify that_ ✓ 74— e'rv_ t-(structure owner)shall <br /> be compensated for any damage fiom the proposed mining operation to the above listed structure(s) <br /> located on or within 200 feet of th�proposed affected area described within k • ibit A.of the Reclamation <br /> .t .,....._ Q_H OM C.�M <br /> Permit Application for G'"a T � , __ _ _v , /-(operation name). <br /> Pile dumber M-77-30. <br /> This form has been approved by the Colorado Afiued Laird Reclanmtion Board parsuarrt to its <br /> authority under the Colorado Land Reclamation Act for rite Extraction oj'Construction Alaterials attrl <br /> the Colorado Mined Land Reclamation Act,/or Hart[Rock,ttletal,and Designated Mining Operations. <br /> Any alteration or modification to this form shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOW-E..E GED BY: <br /> Applicant "sal />'94e' ' " t' I Representative Name__ `- .--. <br /> t fitic <br /> • <br /> Gate __ ,r_., ._�� --�-- - --- - -- ----_ _--__- __ - ----•-- <br /> STATLOF <br /> } l ss. <br /> COUNTY OF ) <br /> l orecxm g was acknowledged before me this day of - (,��---- 20 by <br /> � lh. My Commission Expires: <br /> �. Notary Public <br /> 't Y <br /> lriF dF C44flQQ <br />