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C) <br /> RPM,Inc. <br /> CERTIFICATION <br /> The Applicant,Elbert County Government,Elbert County"County",does herby certify that Elbert County <br /> Govemnmt"Property Owner"shall be compensated for any damage from the proposed mining operation to the <br /> above listed structures(s)located on or within 200 feet of the proposed affected area described within Exhibit A,of <br /> the reclamation Permit Application for the Permit No.M-2001-056 Belveal Gravel Pit. <br /> This forms has been approved by the Colorado Mined Land Reclamation Boarrl pursuant to its authoritp under <br /> the Colorado Land Reclamation Act for the Extraction of Construction Materials and the Colorado Mined Land <br /> Reclamation Act far(lard hock,Metal,and Designated Mining Operations. Any alteration or modification to <br /> this form shall result in voiding this form. <br /> NOTARY FOR PF,RMTT APPLICAN r <br /> ACKNOWLEDGED BY: <br /> Applicant: Elbert County Government Representative Name <br /> Date / ZO�� Titic _�uO�tL� NDEh}�_ Of P►O <br /> STATE OF <br /> i ) <br /> COUNTY OF -_-) (� 3 4 <br /> The f�oregomg,was pc before me this day of<�1�j'\._.2U by �1J C as - <br /> of <br /> My Commission Expires: <br /> 1`'o PUb11C USA MACKfESNiCZ <br /> "rotary Public-State of Colorado <br /> Notary IDJ009,'Ot9061 'OTARY STRUCTURE ONN ER <br /> My Commission Expires Jun 9,2021 <br /> ACKNOWLEDGED BY: <br /> Structure Owner:Elbert County Government Representative Name:M <br /> Date <br /> 1 ( Title_ �!,��i�(7 <br /> STATE OF _ ) <br /> COUNTY OF ) <br /> The foregoing was acknowledged before me this_-__.day of 20_.by - as <br /> Of <br /> Notary Public <br /> 11 <br />