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CERTIFICATION <br /> The Applicant, sacvc r eio 71,4 fr- (print applicant/company name), <br /> by eve/ 61,,w(r (print representative's name),as Gr`4'S (print <br /> representative's title),does hereby certify that Rus TmJy y la (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 6Q/Pie [et 71 f 0e, i'S,rS Tr C (operation name), <br /> File Number M-20/?00,e. <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 /> Applicant (6du/ee #3r0 %A re- S Representative Name Oil temwei. <br /> Date /0-2 -? / 7 Title "r PS' <br /> STATE OF Cot oir ado) <br /> ) ss. <br /> COUNTY OF ) <br /> ci <br /> The foregoing was acknowledged before me this day of OC VIOC\c,20n,by <br /> blest a aO\(V-C1,-- as PYes' CI-c,tA:t- of P;O ji EI)V Othe 1,c <br /> 4,'1 C1l P )�J W v My Commission Expires: 1 O 12S1,2_(:)2-O <br /> iry Publi <br /> JENNIFER RIDNOUR <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID#20044038288 <br /> My Canmmit$on Eipir.R October 25,2020 <br />