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CERTIFICATION <br /> The Applicant, 'tom t (Yli (print applicant/company name), <br /> by � A �_(pri resentative's name), as (print <br /> representative's title),does hereby certify that . 14" (1 �(� (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 �a n �i {operation name), <br /> File Number M-OM-Q.S. <br /> This form has been approved by the Colorado Alined 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 Art for(lard 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 /> ACKNOWL G (� <br /> Applicant Representative Name <br /> Date Title44rvkaa- <br /> STATEOF <br /> ) Ss. <br /> COUNTY OF ) <br /> The foregoing was acknowledged before me this day of _ 20 1 ,by <br /> as i'C�l[�-4 - of ` <br /> . 1 <br /> -- -- <br /> My Commission Expires: -v be3 - <br /> N a Public <br /> :JO01SCHREI®ERRY PUBLIC COLORADON 20064001792COMMISIRES OCTOBER 6.1022 <br />