Laserfiche WebLink
CERTIFICATION <br /> The Applicant, 4l1 �1, - V; mix (� (print applicant/company name), <br /> by �ll,1y�A. (print resentative's name), as Pres-rdeH. - (print <br /> representative's title , does hereby certify that actrL-tHas 1 Ov D. (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 G wtti1 /\Je.S-SCJ1'U t Ti-- (operation name), <br /> File Number M-lgg7 -d19. <br /> This form has been approved by the Colorado Mined 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 Act for Hard 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 /> ACKNOWLEGED BY: I <br /> Applicant All j+e 1 .vij . .Leij Representative Name <br /> Date << t I I g Title �i-egb <br /> STATE OF NjDvZ dO ) <br /> ) ss. <br /> COUNTY OF v ) <br /> The foregoi was acknowledged efore me this I day of f�DyP} - ,A01K, by <br /> 4+Arta asytji 11 - of "oil --)[641�Yj l lac <br /> ( <br /> . My Commission Expires: /o1(pl`9 <br /> Not/ ublic <br /> JODI D SCHREIBER <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20064001792 <br /> MY COMMISSION EXPIRES OCTOBER 6,2022 <br />