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$40 <br />CERTIFICATION <br />The Applicant. Turkey Cation Quarry Inc., byt✓►A,zti Aa 2 G.r Sr as Vi r-�. _L moi, F -•-'y docs hereby certify <br />that ADAM OR MICHELLE SCHUBEKr {structure owners) shall be compensated <br />for any damage from the proposed mining operation to the above listed structure(s) looted within 200 feet of the <br />proposed a%ded arca dcsmi ed within Exhibit A, ofthe Reclamation Permit for Vollmer Pit, <br />File Number M-1983-035. <br />Signature of <br />This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its authority <br />under the Colorado Land Reclamation Act for the Extraction of Construction Materials and the Colorado Mitred <br />Land Reclamation Act for Hard Rock, Metal, and Deaignated ming Operations Airy alteration or modification to <br />this fora shall result in voiding this form. <br />NOTARY FOR PERMIT APPLICANT <br />ACKNOWLEGED BY: <br />Applicant: I�,�,�! Gj uSFJ ( R-� . �i Representative Name:_ <br />(P� �) (Plem p6m) <br />Date: DC•TI)beL q _ U <br />STATE OF COLORADO ) <br />COUNTY OF EI PASO ) <br />The foregoing was aclmowledged before me this day of 2018, by <br />of <br />(si of owner or representative) (title) (company name) <br />7 <br />My Commission Expires: &W 3D ?k)VZ <br />Notary Pubic Signature <br />ERIC S HOWARD <br />Notery Public <br />Sum of Colorado <br />Notary 10 r 201 "021884 <br />MY Commission Expires 06.30-2022 <br />Rase 2 of 3 <br />