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CERTIFICATION <br /> The Applicant, tee Gv t8'd/ ieS-4-(print applicant/company name), <br /> by �r../ 1Ou/er (print representative's name),-- as <br /> a9,'1 (print <br /> �vsrepresentative's title),does hereby certify that '7`y 7 ,/a (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 <br /> affected area described within Exhibit A,of the Reclamation <br /> Permit Application for /'/1/p ,-di 7`r,-.9.r/s 0 ( (operation name), <br /> File Number M-/tV/-2 74' <br /> This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its <br /> authority under the Colorado Land Reclamation Ad 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 Be w c'i— gr Representative Name A/c/ kv t',, <br /> Date /0-2 Y ` / 7 Title {s <br /> STATE OF CO(0lrCq <br /> ss. <br /> COUNTY OFA a( ) <br /> The foregoing was acknowledged before me thic2y of ,20 r1 by <br /> alatt U�OVNC -- as FV-PSi GA CA"--t of nMCI,/ ft-c4.1 G <br /> - 3)t•TiQi (Uno-( cMy Commission Expires: 1012_ ( .2.02_0 <br /> N Publi <br /> JENNIFER RIDNOUR <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID#20044038288 <br /> My Commission Expires October 26,2020• <br />