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i <br /> I <br /> CERTIFICATION <br /> I ' <br /> The Applicant, JH Sand&Gravel, LLC <br /> by Jim MCCuistion (print representative's name),as (pant applicant/company name), <br /> residen <br /> representative's title),does hereby certify that Southeast Colorado Pov� A soct (pst rint <br /> ruc <br /> be compensated for any damage from the proposed mining operation dot the above(iste Lure owner)shall <br /> d structure(s) <br /> located on or within 200 feet of the proposed affected area described vp Ithin Exhibit A o <br /> Permit Application for JH Sand&Gravel,LLC f the Reclamation <br /> File Number M-M1979131 (operation name), <br /> This form has been approved by the Colorado Mined Land <br /> authority tinder the Colorado Land Reclamation Act for the ExtracXtil of Const�tction tMater/als its <br /> the Colorado Mined Land Reclamation Act for Hard Rock,Metal,atr�Designated Mining tOperation.,.and <br /> Any alteration or modification to t/t/s form s/:all <br /> resrilt in voiding t/tisj�`orn>. g <br /> NOTARY FOR PERMIT APPLICA T <br /> ACKNOWLEGED BY: <br /> amajion <br /> Appiican <br /> Representative Name <br /> Date - t dj"�!9 - <br /> Title �rESrc� <br /> STATE OF ., �� ) - <br /> KARA HINKHOUSE <br /> COUNTY QF _ )ss. NOTARY PUBLIC-STATE OF COfRADO_t V NOTARY ID 201840479MY COMMISSION EXPIRES DEC 12022 <br /> The foregoing was acknowledged before me this i day of6 {�, 2U i b <br /> as of -— 9, y <br /> Notary Public MY Commission Expires:.._ <br /> 4_,L <br /> i <br />