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CERTIFICATION <br /> The Applicant, Asphalt Gravel Products, Inc., by Alonzo Salazar, as Office Manager, does <br /> hereby certify that (structure owner) shall be compensated for <br /> any damage from the proposed mining operation to the above listed structure(s) located on or <br /> within 200 feet of the proposed affected area described within Exhibit A, of the Reclamation <br /> Permit Application for the Garrett Pit, File Number M-1978-271. <br /> This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its authority under the <br /> Colorado Land Reclamation Act for the Extraction of Construction Materials and the Colorado Mined Land <br /> Reclamation Act for Hard Rock, Metal, and Designated Mining Operations. Any alteration or modification to this <br /> form shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> Applicant Representative Name <br /> Date Title <br /> STATE OF ) <br /> ss. <br /> COUNTY OF ) <br /> The foregoing was acknowledged before me this day of , 20 , by <br /> as of <br /> My Commission Expires: <br /> Notary Public <br />