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CERTIFICATION <br /> The Applicant, r L.L. C , (print applicant/company name), <br /> by ri� I Kjs (print representative's name), as 6���� (print <br /> 11 <br /> representative's title), does hereby certify that (structure owner) shall <br /> be compensated for any damage from the proposa 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'IdiS C-r�'ave! !�i T (operation name), <br /> File Number M-/_QZ- o3,?. <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 { ,Q(n CCJJvvfru AaaA Rbcki L l-C Representative Name <br /> Date & /f 73 Il $ Title <br /> STATE OF Colorc-Ll p ) <br /> ) ss. <br /> COUNTY OF Q Q j++ ) <br /> The foregoing was acknowledged before me this day of oKQ , 20 , by <br /> 1 R(A S;bso✓t as owner ofjjl4 G► (20"' c ,4 2ock,LLC <br /> My Commission Expires: ! Z <br /> �otarylic <br /> JESSICA UNDERWOOD <br /> Notary Public-State of Colorado <br /> Notary ID 20094039637 <br /> My Commission Expires Dec 4,2021 <br />