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CERTIFICATION <br /> The Applicant, I G�i� s �1�1► (print applicant/company name), <br /> by jA6vj �. � __(prin presentativeIs name), as '-Pi-t�1��M,L-k- (print <br /> representative's title), does hereby certify that�L hp�. �Q-y'�e7 (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 j�/� j- (operation name); <br /> File Number M-614 - 0*3 . <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 /> ACKNOWLE BY: <br /> Applicant Representative Name JWAn -i4r�r <br /> Date Title <br /> STATE OF p ) <br /> ss. <br /> COUNTY OF <br /> The foregoing was acknowledged PSfore me this U day of 20_tq, b <br /> � h " ._as ?dj-,g:'t- of z <br /> My Commission Expires:V �A _/OA%3 <br /> No ublic <br /> HRele" --�_ <br /> PUBLIC <br /> OLORADO <br /> 0064001792 <br /> LOM::012 <br /> ES OCTOBER 6.2022 <br />