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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 Hills 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-2003_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 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 /> r <br /> Applicant `,q U j?. y Representative Namo � �� ��/ ' <br /> Date Title 1744-17 e1r / <br /> STATE OF (pa,/ &,10 ) <br /> ) ss. <br /> COUNTY OF / p �4, ) - <br /> The foregoing was acknowledged before me this day of /1/0 Al , 20Z,57- by <br /> Adie� � 9AUdAc.4vIlas ,WAA 94,,en of f3r4 9"or <br /> � <br /> My Commission Expires: <br /> Notary Public <br /> LNota"10 <br /> ONEY <br /> E of Colorado <br /> 006240 <br /> s Feb 28,2022 <br />