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CERTIFICATION <br /> The Applicant, 1 ) I -l4e_ "PAY?If D( (print applicant/company name), <br /> b ( rint re rese's name), asfilX51 �it- - ( rint <br /> y ��1/� �t' � P PP <br /> representative's title), does hereby certify that eh/Mk) 62:1I &nyIted- h (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 for02)kidAil/ o,S,,S,P)hid- R1- ./L 1 (operation name), <br /> File Number M-M/-7- O71 <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 /> ACKNOWLI IP : ' <br /> Applicant _611111111116'--,-...--"%, Representative Name 14y1 - <br /> 3 <br /> Date i �� Title yeMevi <br /> STATE OF 0.016./., ) <br /> ) ss. <br /> COUNTY OF 1pprni,r,— ) <br /> The foregoing was acknowledged ore me this (.O day of ' I_ ' • 20 I'l, by. <br /> Jell 4 L4 as i9jid 'i of 4 I - k 6✓I ` 17 /n <br /> 0//1 _ A ,-� My Commission Expires: 0 a <br /> 4 <br /> r:`" Public <br /> JODI D SCHREIBER <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20064001792 <br /> MY COMMISSION EXPIRES OCTOBER 6,2022 <br />