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CERTIFICATION <br /> The Applicant, Asphalt Paving Co., represented C'• DFP&?JY^as <br /> VICE �'- iDE7U oes hereby certify that ,�FIVO �h �G,� ,�• (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 tinder <br /> the Colorado Laird 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 forirt. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY. 7 <br /> Applicant j"T-MVIA& Representative Name / ---� <br /> Date �l� Title <br /> STATE OF LihrCLAn ) <br /> ) s5. <br /> COUNTY O _ ) <br /> The foregoing was acknowledged before me this day of _ , 20j,by <br /> IMCLA as U ic�.' s ofVT <br /> r W ly Commission Expires: 1a- <br /> Notary Public <br /> TERESE VIRGINIA LOMBARD <br /> Notary Public <br /> State of Colorado <br /> Notary ID It 20194005945 <br /> My Commission Expires 02-12-2023 <br />