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CERTIFICATION <br /> The Applicant,,( 4L.L. C . (print applicant/company name), <br /> by ri c1t� (print representative's name), as C5(,0ner (print <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 o/��t4r/Ytf'the proposed affected area thin within Exhibit A, of the Reclamation <br /> Permit Application for '/�/1S f T�;f9dis C7A�Cl t/P� !�17L (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 E},,�, (',: ,�{r�1 ilcvr� t?z chi L L C Representative Name <br /> Date & /(3/I g Title 0 k)"e t <br /> STATE OF C v I v rct-j & ) <br /> ss. <br /> COUNTY OF jV :+.t- ) <br /> The foregoing was acknowledged before me this 1 today of cj oike 20 , by <br /> as Cc>r'qrr of a,d Rvct�, .t,�_.� <br /> r My Commission Expires: t Z J g 1 2 c Z I <br /> otary Public <br /> JESSICA UNDERWOOD <br /> Notary Public-State of Colorado <br /> Notary ID 20094039637 <br /> My Commission Expires Dec 4,2021 <br />