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CERTIFICATION <br /> The A)Pllcant, ����-�� C=1���Z� , L� 6)rint 7,-rb <br /> cant/company naine), <br /> by �4 /�fit �n•int representative's name), as w�2�1 (l)ririt <br /> representative's title), does hereby certify that %r k'5:i e Y� (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 T o�� a a� �Y �" _(Operation name), <br /> File Number M� . <br /> This form has been approved by the Colorado Mined Land Reclamation Boun1 pinsuant to its <br /> authority unrler 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 mo(ltf lcation to this form shall result in voiding this form. <br /> NOTAIt'Y FOR PERMIT'APPLICANT <br /> ACKNOWLEGED BY: <br /> RepresentativeName'hn�� <br /> Date Title <br /> STATE Or <br /> ss, <br /> COUNTY Ol,\jj�Z\ � ) <br /> The foregoing was acknowledged before me thi0A day of P�Q�. ,20 by <br /> as dt"i of <br /> My Commission Expires: <br /> No ary Public <br /> ROBIN KVINING <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20024040651 <br /> MY COMMISSION EXPIRES DECEMBER 18,2022 <br />