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CERTIFICATION <br /> The Applicant,The 1st U/;S r £c,tlw et+/Pc s <br /> Qv (print applicant/company name), <br /> by(o 5 4-{A 6. 5c f (print representative's name),as ell.e 5 t cte Ai 'fr (print <br /> representative's title),does hereby certify that 7 (,l eR C 0 L(5 / L C (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 -5 G 014' EL 4, ' 1/ (operation name), <br /> File Number M-14-o31. <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 /> Applicanfflt Ti/lgtic: eCctli/eCE,tepresentativeName <br /> v <br /> 2* , 41/74(----L' <br /> c <br /> Date 3--L-RCI� Title P"rP�IPn 1- <br /> STATE OF&le,r(A c tc) <br /> STATEOF&{c)f(Ack) ) <br /> 4.. ss. <br /> COUNTY 04}Q me--A 1) <br /> _The foregoing was acknowledged before me this(o (Y (`I 1( <br /> bay of I ,20 I by <br /> c`)IVt (_., Jc'cltt as pfPSrd of.-�--hQ--Tufct,lla S1? (ct111ec` c <br /> Fv) <br /> j / <br /> �Ct a �G _ c 1`� L��� My Commission Expires: C R t L'cf'p�� <br /> Notary Public <br /> Paula A Truj <br /> Notary Public <br /> State of Colorado <br /> Notary ID#: 20034006714 <br /> My Commission Expires:04/09/2019 <br />