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CERTIFICATION <br /> The Applicant. <br /> !' -h L z C (print applieanticompany name), <br /> by. : ) {�u� i1 w• vie-c print representative's name),as t"t,l- L,'�� (print <br /> Cry`F .v0► <br /> representative's title),does herebycertit>•that S,� structure owner)shalt <br /> be compensated for any damage from the proposed mining operation to the above listed structure(s) <br /> located on or within 200 feet of tile proposed affected area described within E tbit A,of the Reclamation <br /> ' �i S� — <br /> Permit Application for C'o -� ,c`�'"�'"__ r (operation name), <br /> File Number M- 77 -30. <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 the Extraction of Construction Materials and <br /> the Colorado Mined Land Reclamation Act for Hard Rock,Metal.and Designated Mining Operations. <br /> Atry alteration or modification to this form shall result in voiding this form <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWI-E:GEU BY: <br /> j evZ ice• <br /> Applicant -::! " 9de v%' Rcpresentativc Name <br /> Date <br /> 'Title <br /> STATE OF <br /> )ss. <br /> COUNTY OF <br /> T - bregoi g was ackno«lodged before me this day of _. 20 ,b�, <br /> of <br /> r` <br /> iv1y Commission):xpires:�C. , <br /> Notary Public �4r�'RY-RU��f <br /> T l3rencla � <br /> ------------- <br /> e <br /> s <br /> �,, t <trser JO <br /> " F pF COL�Q4 <br />