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CERTIFICATION <br /> The Applicant, United Companies, Inc. p (printappliicant/company name), <br /> by Q ,Sit lvl' AI (paint representative's name),as V 1 1ASSy.. Sec. (print <br /> representative's tit e),does hereby certify that (struchue owner)shall <br /> be compensated for any damage from the proposed min' g operation to the above listed structures) <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 Actfor Hard Rock,Metal,and Designated Mining Operations. <br /> Any alteration or modification to this fora:shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICA;e,4, <br /> ACKNOWLEGED BY: It <br /> Applicant Ui?t �tL�rt;�����} Representative Name .J• s t aim ym✓ <br /> Date S-ZZ-/' Title ✓P S�� <br /> STATE OF CO ) <br /> )ss. <br /> COUNTY OF /)je f g ) <br /> The foregoing was acknowledged Wpm me thus e2d"day of k:1 ,20 1 ,by <br /> as of <br /> T -" <br /> My Commission Expires: a� <br /> N Public <br /> [NOTAJULIE A. MALMBERG <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> ID#20054003624 <br /> RY <br /> Commission Expires January 27,2021 <br />