2018-12-04_REVISION - M1979131

• Permit No: M1979131
• IBM Index Class Name: Revision
• Doc Date: 12/4/2018
• Doc Name: Incompleteness Notice
• From: DRMS
• To: JH Sand & Gravel
• Type & Sequence: SO1
• Email Name: JPL
• Media Type: D
• Archive: No

CERTIFICATION
The Applicant,
by (print representative's name), as
representative's title}, does hereby certify that
be compensated for any damage from the proposed mining operation to
located on or within 200 feet of the proposed affected area described wi
Permit Application for
File Number M- -
applicant/company name),
(structure owner) shall
above listed structure(s)
Exhibit A, of the Reclamation
(operation name),
This forret has been approved by the Colorado Mined Land Reel mation Board pursuant to its
authority under the Colorado Land Reclamation Act for the Extraction f Construction Materials and
the Colorado Minted Land Reclamation Act for Hard Rock, Metal, and Designated Mining Operations
Any alterations or modifications to this forth shall resull in voiding thisft rnL
ACKNOWLEGED BY:
Applicant
Date
STAT_ E OF }
) ss.
COUNTY OF }
Representative Name
Title
The foregoing was acknowledged before me this day of _
as of
My Commission Expires:
Notary Public
20---, by