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CERTIFICATION <br /> The Applicant,--T—,.-LA(Lo( Cjor\,,Ljc.,,sA (print applicant/company name), <br /> by o t (.ppj( wv (print representative's name), as�� ktci x&rk4 v- (print <br /> representative's title), does hereby certify that �); (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 ?(-O Ne.c-�C- (operation name), <br /> File Number M-2018 La 1 <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 t,( 'U(\lb�c� Representative Name <br /> Date Title <br /> STATE OF (C &) ) <br /> ) ss. <br /> COUNTY OF I&6c j�A ej�- ) <br /> The foregoing was acknowledged before me this day of �` �Ir , 20 ( by <br /> as ' �f <br /> My Commission Expires: <br /> No Publi MELODY S. CONWAY <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20074030422 <br /> MY COMMISSION EXPIRES AUGUST 25,2019 <br />