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CERTIFICATION <br /> The Applicant, C_��r�1S � (print applicant/company name), <br /> by &.\&j ->�- . &�(print representative's name), as 0 c.--�e— I &Z2 OCA.r7' (print <br /> representative's title),does hereby certify that ert0 A e,,Q C-A--S'S (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 fore[ 7;;j-+►' /5&& —rT (operation name), <br /> File Number M-I"I- QF.�.- <br /> This form has been approved by the Colorado Mined Land Reclamation Board pursttant to its <br /> authority wider 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 /> cc . 1.�114-IG6��' <br /> Applicant l�l� (-z�� C��Representative Name <br /> Date f _ — Title _ pc L—N&X-42-- <br /> AHAN <br /> STATE OF C0),G(r� BLAKIC- TA E OF CO <br /> NOTARY PUBLIC-STATE OF COLORADO <br /> ) sS. Notary ID#20194029309 <br /> COUNTY OF My Commission Expires 7/19/2022 <br /> The fore oing was acknowledged before me this day of -w'L�>1� , 201, b <br /> as D I PP.ES14F+JT of -7`�Cd�2 T7M M - <br /> My Commission Expires: <br /> Notary -- <br /> Nota Public <br />