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PERM ITTE E/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 Pueblo County Commissioners own the following structure(s), located within <br /> 200 feet of the permitted mining area: Siloam Road <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 Pueblo County Commissioners shall be compensated for any damage from the proposed <br /> mining operation to the above listed structure(s) located within 200 feet of the permitted mining area described in <br /> the MLR 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 /> Z Signature: 9 Date: 0fly Tq�TgRY� �� <br /> STATE OF Colorado ) co'yti�Tq�o F0 <br /> COUNTY OF Pueblo )ss oNF����Fs'01441 0 <br /> The foregoing was acknowledged before me this day of �aOI���' by <br /> Matthew R. Welte as COO of Summit Brick&Tile CO. '°i <br /> Notary Public: Nay Commission Expires: <br /> NOTARY FOR STRUCTURE OWNER <br /> ACKNOWLEDGED BY: <br /> Structure Owner(s): Pueblo County Commissioners <br /> Contact name(print): Title <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 # 70102780000220634640 <br />