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CERTIFICATION <br /> s. . _...... �.;r-E Y <br /> The Applicant, i��t ge (.7C-tAc Je.` (print applicant/company name), <br /> by -&gks. "Tna.a- (print representative's name), as print <br /> representative's title), does hereby certify that i~ \ Y*v!,o r,n.r5n,SN (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 } <�l ,�, -s,rra�,c.,� ,C. (operation name), <br /> File Number M-J S-05 <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�;,�1 '"j"`r �Y L.LC- Representative Name <br /> Date Trav\ '$ Z414 Title f rta I -� <br /> STATE OF <br /> ss. <br /> COUNTY OF ?<,. , ) <br /> The foregoing was acknowledged before me thisZ2 day of , 2011, by <br /> My Commission Expires: <br /> Notary Public <br /> t)uNNA J.ELLIS <br /> NOTARY PUBLIC <br /> LNOTARY <br /> TATE OF COLORADO <br /> ID 20124002�41 <br /> mmission Expires 01-2 2Q2� <br />