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CEWFIFiCAT10:1 <br /> -"emu f� L�� (print applicant/company name), <br /> The Applicant. � � <br /> by.. , itev L.i,f:�tr.�i(print representative's namn�e)) as 1,,i ,.L,�;�-�" (Pt'int <br /> representative's title),does hereby certify that )A'WAV::S �thaboe <br /> -(structure owner)shall,. n listed structure(s) <br /> be compensated for any damage from the proposed mining operation t° <br /> located on or within 200 feet of the proposed affected area described within li �bii`tt A.of the Reclamation <br /> Permit Application for S_ ___ __.. Y, (operation name), <br /> File Number M-77 <br /> This form has been approved by the Colorado Pruned Land Reclarrration Board pursuant to its <br /> authority render fire Colorado Land Reclanratlon Actfor the Extraction oJ'CMStructiun Material.+"'! <br /> [lie.Colortillo tYlined Land Reclamation Act for Hard Rack Metal,and Deslynureld Minilrr Qperuiic?ns. <br /> Anv alteration or modification to this form shall resuN in voiding this form <br /> NOTARY FOR PERIMYr APPLICANT <br /> ACKNOWLE;GED BY: <br /> Applicant �" r 9--IMAV t' Representative Name <br /> Title <br /> STATE OF <br /> )Ss. <br /> COUNTY Of <br /> .1' y titre oii g vvas acknt-\vlcdged befi re me this da),of (,LLB .2U 1 by <br /> { r_vt-vte as. pr�r l'�t"� of - �c�r �• t�. <br /> My Commission Expires: <br /> NRY!, (Votary (abbe _ U <br /> :-1�� i3rencla•��' <br /> V <br /> t <br /> ;._-. <br /> Ct)L��Qo <br />