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CERTIFICATION <br /> The Applicant, //` l.C., (print applicant/company name), <br /> by GLi (print representative name), (print <br /> presentative s title),does hereby certify th (structure owner)shall <br /> 0 be compensated for any damage from the pro mining operation falhealg iisted 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 (operation name), <br /> File Number MI"9 �w <br /> This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its <br /> authority tinder the Colorado Land Reclamation Act for the Extraction of Construction Materials and <br /> the Colorado Mined Land Reclamation Ad 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 /> Applicant2 /a4 67MRepresentative Name qG�� <br /> Date td/ Title <br /> STATE OF `(JAW ) <br /> )ss. <br /> COUNTY OF n S ) <br /> The foregoing was acknowledged before me this�0 ay of r7 ,20/ 7,by <br /> .-J C�to DulnC K as apev of A& t G, <br /> My Commission Expires: <br /> Notary Public <br /> 0-0' EMU LNPa PHSTER <br /> NOTARY ID•148624W W.3729 <br /> STATE OF LMSUNA <br /> b,+M��+ PARISH OF ORLMNS <br /> my Gonn*WM Is for Lie <br />