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nn 1°1'A til <br /> CERTIFICATION <br /> The Applicant, ,�I� Sav $ Cveavv°, l L.r,.0 (print applicant/company name), <br /> by Jim. MCCuistr 6 (print representative's name), as 95-65 dGn'}' (print <br /> representative's title), does hereby certify that r1.4 4.4410 ,.A,,, CL structure owner) shall <br /> be compensated for any damage from the proposed mining operation to the above listed structure(s) <br /> { <br /> located on or within 200 feet of the proposed affected area described within Exhibit A, of the Reclamation <br /> Permit Application for LTH 15ava004 LLC' (operation name), <br /> File Number M- 11'1 - I 'I �1T�la��C "A'`- roCess. <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 /> Applicant _3 Jed,nil 4 Gaol Representative Nameed14 <br /> ► I <br /> Date I I' J Z 'r g Title egraS`derVL <br /> STATE OF ir; ) <br /> ) ss. <br /> COUNTY OFA ) <br /> The foregoing was acknowledged before me this Z"d'ay of ryay v-N(a2A,20 18, by <br /> C(NCr.CLus4if1;n as PT of �� �a r ��`11,J Q • <br /> My Commission Expires: <br /> No y Public <br /> ANGELA MARIE ALIMN <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20184022187 <br /> MY COMMISSION EXPIRES MAY 24,2022 <br /> 4 <br />