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• <br /> CERTIFICATION <br /> The pplicant, United Companies, Inc. (print applicant/company name), <br /> by ?i� RelyytifflA (print representative's name), as ye As-it ye, . (print <br /> representative's title),does hereby certify that 5 gefk. V I 1 bArr` (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 /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> Applicant Representative Name <br /> Date Title <br /> STATE OF ) <br /> )ss. <br /> COUNTY OF ) <br /> The foregoing was acknowledged before me this day of ,20 ,by <br /> as of <br /> My Commission Expires: <br /> Notary Public <br />