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CERTIFICATION <br /> The Applicant, �.C. (print applicant/company name), <br /> (print representative' name),as (print <br /> / <br /> �j j,lSi mess representative's title),does hereby certify that ' _ ,cox (structure owner)shall <br /> be compensated for any damage from the proposed mining operation 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__Lh my Z. (operation name), <br /> File Number M-/ 8 _0 <br /> This forme 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 APPLICANTtj <br /> oat ,! <br /> /_ <br /> ACKNOWLEGED BY: / <br /> Applicant ��'"'� ,Representative Name G ` <br /> _ L <br /> Date v2 U/�J Title <br /> STATE OF L(XJ1S ICt l a ) <br /> )ss. <br /> COUNTY OF fI LA l5 ) <br /> foregoing was acknowledged before me this of +njj 20 7 by <br /> t CK as -I�lG( ' of /0/,� �L� lf'l <br /> My Commission Expires: <br /> Notary Public <br /> �<<a EMILIE LAUREN PFISTER <br /> NOTARY 0*148524A3AR NO.372 <br /> STATE OF LOUISIANA <br /> PARISH OF ORLEANS <br /> My CW0ft n k for LOP <br />