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CERTIFICATION <br /> The Applicant, ► m, I a SS Sp401S , LLC. (print applicant/company name), <br /> by Lrfaorcrtcc 10; Aeh"(print representative's name),as Vic.c • Pr&sjcic.A (print <br /> representative's title),does hereby certify that JE MAO t�Tfff, 14 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 Jco"y, Ja (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 go's, t1 %6 5,c?4c LLB �Ak <br /> � � Representative Name <br /> Date J,,,riG 2 g l Zv') Title ✓tGe — A2r St A6lv--v <br /> STATE OF --7w,0t4n1--a 9_ <br /> ) ss. <br /> COUNTY OF Vj5 b _ ) <br /> The foregoing was acknowledged before me this Z8 day of -?�AV6 , 20 t8, by <br /> 1,4 y,M4 y C6 ,Q AdA0`1 yV as yur- 'AlQcSt PV17 of m6s.-a 6+.4si 6.0.,rO 5 <br /> 1'yli My Commission Expires: <br /> Notary Public <br /> ,. ., .� Roy H Dressler <br /> State of Indiana <br /> Notary Public <br /> s, Commission No.620360 <br /> My Commission Expires 8/,19/2018 <br />