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CERTIFICATION <br /> The Applicant, YWt print applicant/company name), <br /> (print repre tive's name), as_ �� ,�i { (print <br /> representative's title), does hereby certify that 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 -(IL (operation name), <br /> File Number M- lgly- 113. <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 /> ACKNOW E E <br /> Applicant Representative Name �r�tp,tk <br /> Date d3 Title <br /> STATE OF C ) <br /> ss. <br /> COUNTY OF RefMjl-f ) <br /> The foreg 'ng was acknowledged fore me this day of _, 20 by <br /> asi"P biJ{h-f- ofk� 'i—r�nl air vi <br /> My Commission Expires:_ Z d <br /> (�Notdry ic <br /> =ID2006400 <br /> EIBER <br /> UBLIC <br /> LORADO <br /> 64001792 OCTOBER 6,2022 <br />