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CERTIFICATION 1 <br /> The Applican , I (print applicant/company name), <br /> byjj print representative s name), as (Print <br /> representative's title), does hereby certify that (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 des/c�riibed`/within Exhibit A, of the Reclamation <br /> Permit Application for ! c�t- T 7 (operation name), <br /> File Number M-� r� LP11,_ �f i �`� ��� - v /hco. <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 t or . <br /> f � <br /> f t <br /> NOTARY FOR PERMIT A T <br /> ACKNOWLEGED BY: ' <br /> ApplicantCS—V-642455E�K 0 (2 LL.(Z:i Representati <br /> Date Title ilt5 <br /> i c MOP <br /> STATE OF�� ) `'�� 1 � �� <br /> ss <br /> COUNTY OF <br /> The foregoing was acknowledged before me this day ��r , 201 by <br /> as •— of r <br /> M Commission Expires: <br /> Notary Public <br /> KARLA NICHOLS <br /> FN `YRPUBLIC-STATE OF COLORADO <br /> NOTARY ID 19974015323MMISSION EXPIRES DEC 22, 202', <br />