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CERTIFICATION <br /> The Applicant, z—Z�4 fD8=ZAT,o j (print applicant/company name), <br /> (print representative's name), as ?,(1-��t47.1T � y (print <br /> representative's title), does hereby certify that LA S Lt (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- a -Lb3_Lp. <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 Z At s,( Coati A-D CI J Representative Name <br /> Date Z-S�) 0C=-r Zf-) 1 Title <br /> STATE OF �O O ) <br /> ) ss. <br /> COUNTY OF 1� S o ) <br /> The foregoing was acknowledged before me this day of yt-LD�� 20 1 CK, by <br /> QA&V kS SV b j Wn as Of CQr,PoVrb0r1. <br /> My Commission Expires: la <br /> No blic <br /> STACY TURNER <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20194036379 <br /> my Commission Expires 09-13-2022 <br />