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CERTIFICATION <br /> The Applicant, AIJ11 tk i mix (print applicant/company name). <br /> by (print resentative's name), as -Pr Ri'l ePLk (print <br /> representative's title , does hereby certify that B j& H3 60 p• (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 � d I It A]EA-5eJlLt� �jA-- (operation name), <br /> File Number M-! 8' -A-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 /> Ail}'alteration or modification to this form shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> 4 mix <br /> Applicant Al � Representative Name <br /> Date I& t ►g Title <br /> STATE OF ) <br /> ss. <br /> COUNTY OF V yr , $ ) <br /> The foregoi v was ackno��lodged efore me this l a�dad of f YaY��h 0 Jk <br /> . b} <br /> as — of <br /> of <br /> Nly Commission Expires:L(p/e3a- <br /> Not ublic <br /> JODI D SCHREIBER <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20064001792 <br /> MY COMMISSION EXPIRES OCTOBER 6,2022 <br />