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CERTIFICATION <br /> The Applicant, !�}wm Dr rokmo / (print applicant/company name), <br /> by An&tj ncoi►K (print representative's name), as /U MANA669 (print <br /> representative's title), does hereby certify that d 1, W OF (pMOORY (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 f 096 f 6 X rn/1VE (operation name), <br /> File Number M o` &-030. <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: AA� A#k <br /> Applicant GU/V dF �Dl�/�UBV Representative Name A <br /> Date J2k L y 6, 'QeDIg Title 76 UWA) ///AAM66a <br /> STATE OF ) <br /> ss. <br /> COUNTY OF &A) <br /> vi <br /> The foregoing was acknowledged before me this 6 day of Ju L-y , 20 �g, by <br /> B as I'DZtj MAC A(&r5k Of TDGOIJ 6F6eAN1B y <br /> Cc ?� My Commission Expires: 0�0� <br /> Notary Public <br /> DEBORAH K HESS <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY MY ID 20034028186 <br /> MISSION EXPIRES DECEMBER 4,2019 <br />