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CERTIFICATION <br /> The Applicant,'_�l h # �✓�,'t t'r- )��C�'cj , file-j J, (—C)Y�- (print applicant/company name), <br /> by/VI�U r/, C 9z-\rL�r^-e (print representative's name), as �. (print <br /> representative's title),does hereby certify that T A k U e t-4,lees (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 GV+�n�s 4:� y �,�l �"�ve I S (operation name), <br /> File Number M-UL 2-Q` . <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 resrtlt in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLE�GEDD BY: <br /> Applicant ./"�/ /.��c l'�'L`-`� Representative Name 19�ei r k ( >CA rC/l A <br /> Date <br /> 3 E7 19 <br /> Title (, <br /> 1 <br /> STATE OF UIUYu�O ) <br /> )Ss. <br /> COUNTY OF es(; ) <br /> The foregoing was acknowledged before me this day of Yoh ,20 k ,by <br /> f�VArk (�ctirJFjc+ as dice�fC5WACA OfWh���t1,11,L -r I1—' n,king �'1i ot-k,.►c.�S�or� <br /> /Lc CMG V C(/U My Commission ExpirOS: /I-I Y "0I <br /> Notary Public <br /> RHEDA V. MASLYK <br /> o NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID#201740469W <br /> My Gommimm Expires November 14,2021 <br />