Laserfiche WebLink
CERTIFICATION <br /> oh LLG <br /> The Applicant. (print applicant/company name), <br /> print representative's name),as _ ___ (print <br /> representative's title),does hereby certify that_ ��_ �_�_.,_-•__ (structure owner)shall <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 the proposed affected area descriib� -eed Nvithin V lbiitt A.of the Reclamation <br /> _v__QNOM � 4rMf / <br /> Permit application for --J!!V/// CyT ` !/r (operation name). <br /> // <br /> 1:1le Number M-77-30, <br /> This form has been approved by the Colorado Mined Land Xeclam:ration Board pursuant to ifs <br /> authority under the Colorado Land Reclamation Act for the Extraction of'C'ansiruction Materials and <br /> the Colorado Mined Laud Reclamation Act for Hard Rack,Aletal,and Designated Mining Operations. <br /> Any alteration or modification fir this form shall resuh in voiding this forns <br /> NOTARY FOR PERMIT APPLICANT <br /> AC KNOWI_HGED BY: <br /> Applicant Representative Name <br /> Date �' " i {, f Title <br /> STATL OF s✓'_Li . ) <br /> )ss. <br /> COUNTY OF , ) <br /> T orcn-o.tnaf was acknowledged before me ihisf b\da) of <br /> _- = _ <br /> as__n �rA 1-,,'eC of- jI <br /> Lic <br /> idly Commission Expires:_ G _ <br /> l Notary Public aq� Ry�l1Ql� <br /> .)y'-el�F.CQ4�� <br /> ;n . rice. <br />