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CERTIFICATION <br /> The A licant, United Companies, Inc. (print pplicant/company name), <br /> b J. � (print representative's ST J�•c- • (print <br /> Y <br /> representative's title),does hereby certify that 0 (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 Otter Creek Pit expansion (operation name), <br /> File Number M.2012-050 . <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 /> NOT FOR PERNM APPLICANT <br /> ACKNOWL'E(GEDr-BY: <br /> Applicant V Itit,�ed �,�►'r� s Representative Name 'J. r ✓ Si y � <br /> Date -L Z-1`j Title ✓PT'Z And $cc . <br /> STATE OF <br /> ss. <br /> COUNTY OF <br /> ALJ�aj <br /> h-i <br /> Th foregoing was acknowledgMbeffre me this day of kfl 20 y by4,e as1��st �� of (mot lP <br /> My Commission Expires: <br /> N tiny Pub is <br /> JULIE A. MALIVIBERG , <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID#20054003624 <br /> My Commission Expires January 27,2021 <br />