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CERTIFICATION <br /> The A plicant, �0-0-vle ,A cJ Z_4—\r' Cc 5 _ _(print applicant/company name), <br /> by_ ✓ 00 Xr/ _(print representative's name), as ©µ'.1-tV-f _(print <br /> -representative's title), does hereby certify that O-e5 (�• ��(4'4"kVy Lvx� _(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 c, � a4-P- S i '� _(operation name), <br /> File Number M- -U0. <br /> This form has been approved b1'the Colorado Mined Land Reclamation Board pursuaiit to its <br /> authority under the Colorado Land Reclamation Act for the Extraction of Construction Materials and <br /> the Colorado Alined Land Reclanation Act./or Hard Rock, Aletal, and Designated Mitring Operations. <br /> Any alteration or modification to this foi-in shall result in Voiding this forin. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> Applicant_6 ULMeA S eulv u`5 Representative Name _ <br /> Date 0 5 O� a _I _ - _ r'_ <br /> ROBIN K VINING <br /> STATE OF _) NOTARY PUBLIC <br /> Ss. STATE OF COLORADO <br /> COUNTY OF e.� NOTARY ID 20024040651 <br /> -- ) MY COMMISSION EXPIRES DECEMBER 18,2022 <br /> The foregoing was acknowledged before me this day of 20'1 , by <br /> Wt as OXJt1L(2_ P�v�e__ of ��- a.��rI ems <br /> My Commission <br /> o ary Public <br />