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CERTIFICATION <br /> The Applicant,_ Yl = / .Iprint applicant/company name), <br /> b? �- _ _ (print rcprr` tative's name),as-- _ � _{print <br /> representative's title), does hereby certify that f.,, _}2r3 (structure owner)shall <br /> be compensated for any damage fi•om the proposed mining operation to the above listed structure(s) <br /> located on or within 200 feet o//f'�the__proposed affected area described within Exhibit A,of the Reclamation <br /> Permit Application For (operation name), <br /> File Number M-Aq- OZ. <br /> This firm has bees approved by the Colorado Mitred Land Reclamation Board pursuant to its <br /> authority toiler the Colorado LaW Reclamation Act for the Extractiott of Construction Materials and <br /> the Colorado Mined Laud Reclantatio»Act for Hard Rock,Metal, mid Designated Mitring Operations. <br /> Atq alteration or modification to this form shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNONVI l;( f. ) <br /> Applicant Representative Name ja\n PqAyll <br /> Date- ..__ v � — _ _ _ Title <br /> ss. <br /> COUNTY OF.F°wot —) <br /> The foregoing was acknowledged b •)re me thi• a) of -__ 1 !_. 20 by <br /> as . d� — _ of- � .. tk <br /> My Commission Expires:_ _ <br /> \rn<n r Ic <br /> fn0 fRE BFR <br /> NOTARY PUBLIC <br /> STATE Of COLORADO <br /> NOTARY 10 20064001782 <br /> LIMY COt.L'."SS.ON EXPIRES OCTp- 8CR 0,2022 <br />