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CERTIFICATION <br /> The Applicant, 1� L/�(�S�rV LQ �, Y (print applicant/company name), <br /> by L, Nn K Ni,IUt, (print representative's name), as coM M i ssl6m c 2 (print <br /> representative's title), does hereby certify that PZ- kI N 5 (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 A-�5h 1LAl i Y (operation name), <br /> File Number <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: <br /> Applicant �l t 1 -SC1 CbLLaRepresentative Name <br /> Date �J_1.c�I e- �, - C, ' Title \-,C L cl,1 C,t r�63 1 t S-S ��I� <br /> STATE OF 0CjKtt j C, ) <br /> COUNTY OF t ) ss. <br /> The fore oing was acknowledged before Tthis_ Zday of l , 20 by <br /> 1 i 14A-1)ut -)c as(., C,i�r� of i _Cif ell C i✓ r1 , <br /> My Commission Expires: <br /> otary Public <br /> PAULA S WEEKS <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20064027129 <br /> MY COMMISSION EXPIRES AUGUST 20,2020 <br />