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CERTIFICATION <br /> The A plicant, United Companies, Inc. VP (print applicant/company name), <br /> by J(print representative's name),as rI t� SeC (print <br /> representative's title),does hereby certify that�l 9 Xf- V) S� (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-c = 4 . <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 Muffed 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 l///4/7eW Cjg f lI 5 till. Representative Name 11s<r r 5� � <br /> i 001 <br /> Date ld—4 / Title �/� AS>C 5cC <br /> STATE OF CD/C(40) ) <br /> )ss. <br /> COUNTY OF PSCL ) <br /> Th foregoing was acknowledged before me thi0l'ti day of �&f_ ,20/�/,b <br /> �t -T S r e M cf as V.P. 5 5'1 S t°C. of ,J�rC Cohl Ck d r'l5 <br /> My Commission Expires: <br /> Notary Public <br /> [GEN7EVIEVE MARIE i3LECHARY PUBLIC <br /> F COLORADO <br /> N #19914003259C Expires April 4,2023 <br />