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CERTIFICATION <br /> The Applicant, //` �.� (print applicanticompany name), <br /> by (� (print representative' name),as _ <br /> • (print <br /> aL61 rl eSS representative's title),does hereby certify that (structure owner)shall <br /> be compensated for any damage from the proposed mining operation to 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 C� . - - - ,-I (operation name), <br /> File Number M-/09 —A�W <br /> This form has been approved by the Colorado Mined Land Reclamation Board pursuant to ifs <br /> authority under 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 fornL <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: � j � <br /> Applicant ��'"� <br /> �Representative Name <br /> L <br /> Date Af 4:;�d/7 Title <br /> STATE OF <br /> )ss. <br /> COUNTY OF 6(11-ectns' ) <br /> lh <br /> The foregoing was acknowledged before me this flay of7n� ,20/7,by <br /> I i if»i'K as /llltrl�tr of /� ��i!"1�3�1��a ;cL <br /> My Commission Expires: U� <br /> Notary Public <br /> +.•°' EMU LAUREN PRSTER <br /> NOTARY ID#14024gAR NO.37258 <br /> STATE OF LOUISIANA <br /> It,,,",,,f' PARISH OF ORLEANS <br /> My CarMniwm Is for ble <br />