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CERTIFICATION <br /> The Applicant, //` 4 C. (print applicant/company name), <br /> (print representative' name),as _ <br /> (print <br /> representative's title),does hereby certify that stru re owner)shall <br /> be compensated for any damage from the proposed mining operation to the a ve li 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 _ d,Q/� (operation name), <br /> File Number M-/ 8 A�l <br /> This form 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 APPLICANT II JJ <br /> ACKNOWLEGED BY: <br /> Applicantp ��67MRepresentative Name , <br /> Date 0/ Title,&.26" <br /> STATE OF� �) <br /> )ss. <br /> COUNTY OFU�( I) <br /> The foregoing was acknowledged before me this��Ilay of 4o'/ ,20/-4 by <br /> �, • I 1,�ir�-rh�� as 1Llicn r ofrn�� nmaalt,., `�C <br /> My Commission Expires: <br /> Notary Public <br /> (0,00--iao-q� EMU LAUREN PLASTERNOTARY ID#148824SAR NO.37258 <br /> STATE OF LOUISWrA <br /> PARISH OF ORLEANS <br /> Ift CWndision is br I* <br />