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CERTIFICATION <br />The ADalica <br />print applicant/company name), <br />by `t Ari [ 0 b,5 6r, (prin't representative's name), as d (prix <br />representative's title), does hereby certify that {structure owner) shall <br />be compensated for any damage from the propos 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 forM�ZM' 'S (operation name), <br />File Number M -/f <br />This firm 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 far 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 />Applicant �% , jj:4— Ia, Representative Name Ar,`1 Si ,650ei - <br />Date (Pi l g 11$ <br />STATE OF LDra-- o } <br />)Ss. <br />COUNTY OF } <br />Title 6 wvlf. r <br />The foregoing was acknowledged before me this I 3L11,day of e_�, 20 f, by <br />L4 rt,so as owvyfr- of 14iatk aej oG LLC <br />_ My Commission Expires: ) Z j 41 2 oz( <br />otary Public <br />JESSICA UNDERWOOD <br />Notary public - State of Colorado <br />Notary ID 20094039637 <br />Arty Commission Expires Dec 4, 2021 <br />