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dtr69 <br /> { CERTIFICATION <br /> The Applicant, /!+e eru/1'4 ua i 5'e (-6 A/4/e/ t'/G it/ (print applicant/company name), <br /> by�d5+eit G.. <br /> (print representative's name),as i4 P 514 t'r1/ -f` (print <br /> representative's title),does hereby certify that C i"t y c e C 4,/it f (4 re K(suture 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 - 5 Gf- 6c * L a.eJ ( (operation name), <br /> File Number M-2447-03/. <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,Meta4 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: / y ,r <br /> Applicant /,/y>y- /1,c 7 t �`'S c( ,l q/J 'Wepp ser entative Name /—e2S f /`;_5'+t-,,,tt- <br /> Date //1`t 1 Et G l 5--/ Yi/ r3 Title i 7 e-re't i / <br /> STATE OF (_? ) ) <br /> / )ss. <br /> COUNTY OF �/ (�� ) <br /> The foregoing was ac owledged�efore me this-5:i day of ' ,20Lgby� <br /> Fb54-er�C07F,t as tre'i eek 1¢ of Td'%Ur/..ST'(L/-14 eta- U vi <br /> d <br /> tel/ ,1`‘Z a_7V(36/14;Commission Expires: 05 1 aZ/ <br /> Notaryyublic <br /> ti MARGARET REYNA HAZLETT <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20134053577 <br /> MY COMMISSION EXPIRES AUGUST 23,2421 , <br />