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The following structures are located on or within 200 feet of the proposed affected area: <br /> 1. Temporary and permanent storage facilities <br /> 2. Dirt roads <br /> 3. Fencing <br /> 4. Utility pole(s)for electricity distribution. <br /> CERTIFICATION <br /> The Applicant, Arcosa Materials, Inc. by Stuart McQueen,Plant Manager,does hereby certify that Mr. <br /> John Sainsbury shall hereby be compensated for any damage from the proposed mining operations to the <br /> above listed structure(s) located on or within the proposed affected areas described within Exhibit A of the <br /> Reclamation Permit Application for Arcosa Lightweight—Boulder facility,File Number M-1988-108 <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 far 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 /> t <br /> Applicant: Arcosa Materials,Inc. Representative Name: Stuart Mc uee <br /> Date: 7f 39 /ogoL4 Title: Plant Manaizer <br /> STATE OF COLORADO ) <br /> ) ss. <br /> COUNTY OF BOULDER ) <br /> The foregoing was acknowledged before me this,3aday of , 201, by <br /> Stuart McQueen as Plant Manajzer of Arc sa Materials, Inc <br /> - W It," My Commission Expires: 07/27/2022 <br /> N Public <br /> HERYL MEUNO <br /> NOTARY PUBLIC <br /> SPATE OF COLORADO <br /> NOTARY ID 20184030332 <br /> MY COMMISSION EXPIRES 07/27JM22 <br />