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CERTIFICATION <br /> The Applicant, �l ► Vl\,ik I vlC (print applicant/company name), <br /> by A\0_hv� �. (prin resentative's name), as +--e gi c6k-� (print <br /> representative's title), does hereby certify that 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 Buss Barrow Pit (operation name), <br /> File Number M-201'1- 03i. <br /> This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its <br /> atithority tinder 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 inn voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> �P <br /> Applicant Representative Name 'hiNY.. <br /> Date sl l l !�! Title <br /> STATE OF LO vz, .o ) <br /> ss. <br /> COUNTY OF Mso, ) <br /> The foregoing was acknowledged before me this l day of , 20 19, by <br /> as Qv-P*AXLd of edx 4II,�c. <br /> z <br /> My Commission Expires: loL62a D- <br /> N to Public <br /> E <br /> I D S=- ERG. <br /> TARE OFRY ID EXP <br />