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CERTIFICATION <br /> The Applicant, United Companies, Inc. (print applicant/company name), <br /> by �� 1'1' :.�. ,,1��-�,''.u�a�r. (print representatives name),as ;: d ,;t.t (print <br /> representative's title),does hereby certify that t ^�� w /l Sfr ucture owner)shall <br /> be compensated for any damage fiom 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 /> ACKNOWLEGF,D BY: <br /> Applicant 6�r_,, IWG Representative Name L � en e&AAW <br /> Date Title <br /> STATE OF Co Ia r6 <br /> ss. <br /> COUNTY OF 'e 56i ) <br /> The foregoing was acknowledged fo,"ne t is90 day of �M ,20/1,by <br /> ef�rJ', t as of � ewgwQnr'CS_ UAC <br /> SS-il gll j�e JA4 jP 1� My Commission Expires: lr O�y -3 <br /> Notary Public <br /> GENEVIEVE MARIE BLECHA <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID#19914003259 <br /> My Commission Expires April 4,2023 <br />