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CERTIFICATION <br /> The Applicant, United Companies, Inc. (print applicant/company name), <br /> by eeff '"J. S?4rtjgj (print representative's naive), as P r i� C (print <br /> �� <br /> representative's title , does hereby certify that( .`�' � s cture owner shall <br /> ) Y fY � ) <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 affected area described within Exhibit A of the Reclamation <br /> proposed <br /> Permit A lication for Otter Creek Pit expansion o eration name <br /> pP ( P ), <br /> File Number M 2012-050 . <br /> This orin has been approved b the Colorado Mined Land Reclamation Board rrrsuant to its <br /> .f PP Y P <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 />