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CERTIFICATION <br /> The Applicant, (print applicant/company name), <br /> by (print representative's name), as (print <br /> representative's title), does hereby certify that (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 (operation name), <br /> File Number M- - <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 /> ACKN;0 EGED BY: NOTARY FOR PERMIT APPLICANT <br /> ACKNO EGED BY: <br /> Applic Representative Nane <br /> Date p a(� a Ol Title ©U Ij 0- VK� / <br /> STATE OFL j_,,r, ,4ha) <br /> ) ss. <br /> COUNTY OF L4, 114.rib) <br /> The foregoing as acknowledged efore me this zG day of 1� , 20,[�, by <br /> AJ �.A as +.tJ� ? of ,;_ _c (�wir.2��->���. 1 �AwG'lCi. ,, 41(_ <br /> My Commission Expires: �� 7'ZL�zC� <br /> N Public <br /> VMj <br /> WALKER <br /> PUBLICCOLORADO20004031276XPIRES 11/14/2020 <br />