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CERTIFICATION <br /> _emu t print applicant/company name <br /> The Applicant. _.. _ � � (l ), <br /> by t -. 1,=.•r��'�f"(print representative's name),as (print <br /> representative's title),does hereby certify that E7 !'�''" �® tructurt owner)shall 9-0?17: � <br /> be compensated for any damage#i•om the proposed mining operation to the above listed structure(s) <br /> located on or within 200 feet ofth,proposed affected arcs de/scribed within I, tbit A.of the Reclamation <br /> Permit Application for� C'�' S'. � _ _ /// ._ __. _ � (operation name). <br /> Pile Number tit-7T-30. <br /> Tltis form has been approved by the Colorado A?'ined Land Reclamation Board pursuant to its <br /> authority under the Colorado Land Reclamation Act for the Extraction of Construction ikfaterials lr)"I <br /> the Colorado Afined Land Reclamation Act for Hard Rock,Afeial,and Designated Mining Operations. <br /> Any alteration or modification to this form shall result in voiding this form <br /> NOTARY FOR PI;Rwir APPLICANT <br /> AC'KNOWt-E;ULD BY: <br /> Representative Name <br /> Dale Title <br /> STATE OF <br /> t )ss. <br /> COUNTY OF—'- <br /> I �)rcgon f:�wa�s tacknov,lodged before me this day of (�{,r+t �0�J b} <br /> My Commission Expires:�..� <br /> l Notary Public ,V�t,flY pU6' <br />