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CERTIFICATION <br /> The Applicant, (print applicant/company name), <br /> by (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 described within Exhibit A,of the Reclamation <br /> Permit Application for <br /> (operation name), <br /> File Number M- <br /> This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its <br /> arrthority 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 /> A►iy alteration or modification to this form shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> Applicant Representative Name <br /> Date Title <br /> STATE OF ) <br /> COUNTY OF ss. <br /> ) <br /> The foregoing was acknowledged before me this day of 20_ b <br /> as of y <br /> Notary Public <br /> My Commission Expires:_ <br />