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PERM ITTEE/STRUCTU RE OWNER AGREEMENT <br /> Mine: Fox No 1 Clay Pit-M-1977-219 <br /> State of Colorado, Mined Land Reclamation (MLR)law requires the permit applicant(operator/permittee)to agree <br /> to reimburse the owner of any permanent man-made structure(s)within 200 feet of the permitted mining area,for <br /> damage done to the structure(s)as a result of the permitted operation. <br /> Summit Brick and Tile Co. believes Shelley Stuart Bullock own the following structure(s), located within 200 feet of <br /> the permitted mining area: fence <br /> Summit Brick and Tile Co. agrees to reimburse you for any damage done to the listed structures as a result of the <br /> mining operation. Your acknowledging signature and a notary seal in the spaces provided below shall satisfy the <br /> MLR law requirement. Summit Brick and Tile Company certifies this agreement as follows: <br /> CERTIFICATION: The Applicant Summit Brick and Tile Co. represented by Matthew R. Welte as COO, does <br /> hereby certify that Shelley Stuart Bullock shall be compensated for any damage from the proposed mining <br /> operation to the above listed structure(s)located within 200 feet of the permitted mining area described in the MLR <br /> Permit for the Fox No. 1 Clay Pit. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEDGED BY: <br /> Permit Applicant: Summit Brick and Tile Co., P.O. Box 533, Pueblo 81003 <br /> Representative: Matthew R.Welte. COO-719-542-8278 <br /> Signature:rl/mil& �� Date: 7 20/ KATHLEEN A.CLEMENTI <br /> NOTARY PUBLIC <br /> STATE OF Colorado ) STATE OF COLORADO <br /> NOTARY ID 20144043948 <br /> )Ss MY COMMISSION EXPIRES NOVEMBER 112018 <br /> COUNTY OF Pueblo ) <br /> The foregoing was acknowledged before me this�AW day of L 2017, by <br /> Matthew R. Welte as COO of Summit Brick&Tile CO. <br /> Notary Public: <br /> D� y Commission Expires:j%� �"'.OGC <br /> NOTARY FOR STRUCTURE OWNER <br /> ACKNOWLEDGED BY: <br /> Structure Owner(s): Shelley Stuart Bullock <br /> Signature: Date: <br /> STATE OF ) <br /> )ss <br /> COUNTY OF ) <br /> The foregoing was acknowledged before me this day of , 2017, by <br /> Notary Public: My Commission Expires: <br /> SENT TO STRUCTURE OWNER VIA CERTIFIED MAIL # 70102780000220634510 <br />