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CERTIFICATION <br /> The Applicant, I h e r gczac;5 i < c f.6 i,' (print applicant/company name), <br /> by re:.5#al (- _5 CG 1t (print representative's name),as Pi/4',I le II/ 1— (print <br /> representative's title),does hereby certify that ;' LR ' ; , structure owner1 �y <br /> be compensated for any damage from the proposed mining operation to the above sted structure(s) pe B � ���' <br /> located on or within 200 feet of the proposed affected area described within Exhibit A,of the Reclamation <br /> Permit Application for $ C., Pt ), (operation name), <br /> File Number M-24463/. <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 <br /> ACKNOWLEGED BY: <br /> // ./� (J <br /> Applicant�f)p TcIR uCi r�Uf' � I <br /> C� �,, C t.�-�a�Representative Name <br /> Date �.,�G I r, Title t S i o•'r ld <br /> STATE OFC:VZt(.1,A0 ) <br /> t,— )ss. <br /> COUNTY OF't"C OY1C, k) <br /> The foregoing was acknowledged before me this011 day of et(),(Sec V) ,20( ,by <br /> Pr (1c1Das 11) eSIC 1€ of-rheTLir iSf Ce_, c-b4`v� <br /> ? c ��� ' My Commission Expires:CI - Cj <br /> Notary Public <br /> Paula A Trujillo <br /> Notary Public <br /> State of Colorado <br /> Notary ID#:20034006714 <br /> My Commission Expires:04/09/2019 <br />