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Mla-Pi 01 <br /> CERTIFICATION <br /> 1 <br /> The Applicant, ,-I-1Sawu� G YdVel J..L (print applicant/company name), <br /> by �J��rv� Mce,,,isfron (print representative's name), as 91-65 t difinit (print <br /> representative's title), does hereby certify that 3 4 5a,vvi4Gr&vds L.L .(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 J H 5a Kd .�1 `LL�/ (operation name), <br /> File Number M-11;11q - 1')1 . `%�; •C'0+ r'1- t v‘ ?roce56. <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 Extractiok 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.orm. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> 4 • Q644:40gy, <br /> Applicant 1-14 se,Kd ' Gaol Representative Name / r <br /> Date 12' J Z ~(1 Title 7'Ug1J9PVt <br /> STATE OF ) <br /> ) ss. <br /> COUNTY OF ) <br /> 'fhe foregoing was acknowledged before me this 12Shd'ay of i-Ly -qh.-V\4 20 Ig, by <br /> auAc- l-1 ri;r- as pi"t.SVA5LI - of S 1c Sa`'w-4-41 xo Q <br /> My Commission Expires: <br /> No y Public <br /> ANGELA MARIE ALWIN 1 i <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20164022187 <br /> 1. MY COMMISSION EXPIRES MAY 24,2022 <br />