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CERTIFICATION <br /> The Applicant, pour aia SS SgndS , LLC. (print applicant/company name), <br /> by LoorcgcG 1, jNJ�,.�,;,(print representative's name},as Vicc ems*t a✓� (print <br /> representative's title),does hereby certify that V4 M,00 afff, U-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 Jerna eja ;,n tr c (operation name), <br /> File Number <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 /> Applicant 54--� � LLB Representative Name <br /> 'Date Jr,ri� ?—$ Zo'1 Title ✓ic.G ,r;5t A6 <br /> STATE OF :XwVi,gni� <br /> ) ss. <br /> COUNTY OF ✓IS'b ) <br /> The foregoing was acknowledged before me this 28 day of J&-, 6 , 20 t8, by <br /> I-Awre4r✓C,6 ,0 09A* 1YV as VccE JPecS1,0a/17 of Howie 6L4ss S.4-yy5 <br /> �YV My Commission Expires:_ 6-<?— Zoy T <br /> Notary Public <br /> Roy H Dressler <br /> State of Indiana <br /> Notary Public <br /> �� • �,� Commission No.620360 <br /> My Commission Expires 8,19/2018 <br />