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CERTIFICATION <br /> The Applicant, (,4 IZ)/ f t/, ('O2.LA ck (print applicant/company name), <br /> by (print representative's name), as (print <br /> representative's title), does hereby certify that /s/A 7& fp.i5i s7vc , (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 G — (operation name), <br /> File Number M72.0/4- d6,.7 <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 /> ACKNOWLE ED BY: <br /> Applic. . ' 6-1-214( Representative Name <br /> P <br /> Date - 10 - C>� 1 Title I(Ad\N 1(k l xi <br /> STATE OF (lA( '((l(c() ) <br /> ) ss. <br /> COUNTY OF e\ vka) ) <br /> The foregoing was acknowledged before me this Play of•Yp-'tyV\O(( , 20 (71by <br /> lrl) tc_yAtit( k as ,Iu\ (\Va\ of 1/1 (-) .. <br /> My <br /> My Commission Expires: (1 -3 6/ r( Q 0 <br /> Notary Public <br /> MELINARYPBE�GERo <br /> STATE OF COLORADO <br /> NOTARY ID 20124012140 <br /> MY COMMISSION EXPIRES FEBRUARY 24,2020 <br />