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CERTIFICATION <br /> The Applicant, AMIA15 R91 STONE (print applicant/company name), <br /> by.Shayj yWe*,k5ov1 (print representative's name), as ; (print <br /> representative's title), does hereby certify that CMAD TWSI 5 structure owner) shall <br /> be compensated for any damage from the proposed mining operation tot e 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 NS (operation name), <br /> File Number M- <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 firm. <br /> rm. <br /> NOTARY FOR PERMIT APPLICAN <br /> ACKNOWLEGED <br /> Applicant A RK I IDS PA KK STOIF Representative Name <br /> Date Title ` <br /> STATE OF ) <br /> ss. <br /> COUNTY OF ) <br /> I <br /> The foregoing was acknowledged before me this day of Ovum QQ - , 201 ', by <br /> �V kr-; . IA) nC-IOV► as CWA9Meably GF1ice of c <br /> �L My Commission Expires: (p l3 <br /> Not ublic <br /> r McKENNA HUNTER <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID#201840246M <br /> k MY COMMISSION EXPIRES 06/1312022 <br />