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CERTIFICATION <br /> The Applicant, z—Z,4 (Aq,,j CZ(jXQjtTiprj (print applicant/company name), <br /> (print representative's name), as (print <br /> representative's title), does hereby certify that LkS (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 w� P�'(LaJ?��L �,-tom '� � ,c�7 (operation name), <br /> File Number M- ,,�� h. <br /> This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its <br /> authorit3, 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 1 1 J Representative Name <br /> Date C r Zf—) 19 Title <br /> STATE OF �G O ) <br /> ) ss. <br /> COUNTY OF ??CLSO ) <br /> The foregoing was acknowledged before me this day of CC-�D�� 20 , by <br /> CkAV VES SV b%Wn as of ZN M j r CA,v jpov&_b 0r%. <br /> My Commission Expires: <br /> No blic <br /> Z \�J— <br /> STACY TURNER <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20184036379 <br /> My Commission Expires 09-13-2022 <br />