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CERTIFICATION <br /> The Applicant, Daniel J. Gaudreault & Barbara J. Gaudreault (print applicant/company name), <br /> byDaniel J. Gaudreault (print representative's name), asOwner (print <br /> representative's title), does hereby certify that Black Wills Energy (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 Big "G' Gravel Pit (operation name), <br /> File Number M 9003_081 <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 Extrraction 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 /> ACKNOW LEGED BY: <br /> Applicant -a j?7- Representative Nam <br /> Date Title /y1Aw t ? eic <br /> STATE OFy <br /> ) ss. <br /> COUNTY OF p v } <br /> The foregoing was acknowledged before me this day of /&/0 P" , 20ZEby <br /> Aug? e.jv tas of 13 / je,4yle <br /> My Commission Expires: <br /> Notary Public <br /> MARONEYc-State of Coloradolt)20104006240F7TIHOWAS <br /> W Vxpires Fab 28,2022 <br />