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CERTII+ICATION <br /> �v�v� 5 ('�d'v\L� (print applicant/company name <br /> The Applicant, ), <br /> by OQAe k /3e,(a4,,Vrint representative's name),as �.��f' �a�-�w+� (print <br /> representative's title),does hereby certify that pe1�cr pn tm.,� 1' ,, lstrueture 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 O` a� (operation name), <br /> File Number M-aLyb- <br /> This form has been approved by the Colorado Mined Land Reclamation Boned pursuant to its <br /> authority under the Colorado Land Reclamation Act for the Extraction of Constriction Materials and <br /> the Colorado Mined Land Reclamation Act for Hard Rock,Metal, and Designated Mining Operations. <br /> Any alteration or inodylication to this form shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> Applicant7y-��L�� S`� �� -1 Representative Name <br /> Date Titled <br /> STATE OFWS0 <br /> )SS. <br /> COUNTY OPVJ o� ) <br /> he foregoing was acknowledged before me this \ day of , 20 bt <br /> c�-na asckiA es--�'oc tL of <br /> My Commission Expires: QQ,C�- -= �� a <br /> otary Public <br /> ROBIN K VINING <br /> i NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20024040651 <br /> i MY COMMISSION EXPIRES DECEMBER 10,2022 <br /> I <br /> I <br /> f{ <br /> l <br />