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CERTIFICATION <br /> The Applicant, 4L4 UW-4 QAt)e:#...,I (_L-C . (print applicant/company name), <br /> by e�JAALf�.. (print representative's name),as_(,jZs..X _ I pQC-f-A 0IC-(print <br /> representative's title),does hereby certify that struclur owner)shall <br /> oe 7/rlEOF -7"i4s <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 MLki .E CtA.&-e- &-A-t/EL , Ltd (operation name), <br /> File Number MZkW-LM <br /> This form has been approved by tlee 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 PERART APPLICANT <br /> ACKNOWL .GED BY: <br /> i <br /> Applicant _ Representative Name �� <br /> Date 7`/fp r r'J _ Title ©wee. <br /> STATE OF CCII-ce.Aoo) <br /> )Ss. <br /> COUNTY OF-7-*u 1e- ) <br /> f1e oregaing was acknowledged before me this 16 day of ,mrr ,201q,by <br /> A-1m., /A�Wt L-._.- My Commission Expires:_ 11 /.3 ao a _ <br /> Notary Public <br /> DEBRA L SHIPMAN <br /> NOTARY PUBLIC•STATE Of COLORADO <br /> Notary ID#20184043955 <br /> M Commisslon Ex res 11/1312022 <br />