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CERTIFICATION <br /> The Applicant, Asphalt Paving Co., represented b- LAC'• � as <br /> Vl�C F�A , does hereby certify that- <br /> _ 1_- 45 _(structure <br /> owner) shall be compensated for any damage from the proposed mining operation to the <br /> above listed structure(s) located on or within 200 feet of the proposed affected area described <br /> within Exhibit A, of the Reclamation Permit Application for Ralston Quarry, File Number M- <br /> 1974-086. <br /> This fornr has been approved by the Colorado Mined Land Reclamation Board pursuant to its authority under <br /> the Colorado Land Reclamation Act for the Extraction of Construction Materials and the Colorado Mined Land <br /> Reclamation Act for Hard Rock, Metal, and Designated Mining Operations.Any alteration or modification to <br /> this form shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> Applicant AP1 1- / I Representative Name <br /> Date L 1 ZVol l q Title V!6E <br /> STATE OF ) <br /> ) ) ss. <br /> COUNTY O <br /> The foregoing was acknowledged before me this + day of &p�-1 �- , 20g, by <br /> OPP Mhk as of`f 4 PtW t to Cz.) <br /> My Commission Expires: <br /> otary Public <br /> TERESE VIRGINIA LOMBARD <br /> Notary Public <br /> State of Colorado <br /> Notary ID U 20194005945 <br /> My Commission Expires 02-1 2-2023 <br />