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CERTIFICATION <br /> The Applicant, AMAZON ITE MINING, LLC (print applicant/company name), <br /> byJEFFREY S. FORREST(print representative's name), as OPERATOR (print <br /> representative's title), does hereby certify that USDA FOREST SERVICE (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 described within Exhibit A, of the Reclamation <br /> Permit Application for FORREST MINING PROJECT (operation name), <br /> File Number M- - <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 /> Any alteration or modification to this form shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> p �tF��,�� �3 ���R� <br /> Applicant Representative Name <br /> Date ��E'er t�-�J?i i� �.��t`l Title C)� T->v-,� <br /> STATE OF ) <br /> ss. <br /> COUNTY OF ) <br /> G� 1 <br /> he oregoin was acknowledged before me thi day of 1 ,20�,by <br /> e �' as C2CW r }�jr of OYl ale M'YI 1►'�� LL C- <br /> My Commission Expires \QAtQiV1 t 3, <br /> Notary ubli <br /> KRISTIN ZAMORA PETERS <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20154035035 <br /> MY COMMISSION EXPIRES SEPTEMSER 3,2019 <br />