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CERTIFICATION <br /> The Applicant, Asphalt Paving Co., represented bye„7�¢ I-6-Y 4f.019&^Is <br /> V16 s�/l-)Q es hereby certify that J �E: ;QFAi-3�25-- (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 form has been approved by the Colorado Mined Land Reclamation Board pursuant to its authority turder <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. An},alteration or modification to <br /> this form shall result in voiding this fornt. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> Applicant7"7- 7A IAJ6- Representative Name <br /> Date jNL 1 167 Title Vk,' <br /> STATE OF ) <br /> ss. <br /> COUNTY O ) <br /> The foregoing was acknowledged before me this day of r t _, 2011, by <br /> oval 11 as � I C TAU i CO. <br /> C� kid-tnU� My Commission Expires: a'� I-a-12�33 <br /> Notary Public <br /> TERESE VIRGINIA 1OMBARD <br /> Notary <br /> ar Public <br /> State ofColorado <br /> Notary ID 020194005945 <br /> MY Commission Ex ires 02-]2-2023 <br />