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fF <br /> ,�6� �Wf LC <br /> CERTIFICATION <br /> The Applican , (print applicant/company name), <br /> by pMtp/nesen ative's name), as fi r (print <br /> representative's title), does hereby certify that pp (structure owner) shall <br /> be compensated for any damage from the proposed mining operation ove 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 (operation name), <br /> File Number M-M!qk 11Z4 <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 orm. <br /> NOTARY FOR PERMIT APPLI <br /> ACKNOWLEGED BY: <br /> Applican `L - Representativ J <br /> Date r— Title AIPJA-C—1 dGiJ i1E5 <br /> STATE <br /> ss. M C 4ZP 0-0 <br /> COUNTY OF S) <br /> The foregoing was acknowledged before me this day of , 20LJ, b <br /> as of Elk Gy L 5,, <br /> My Commission Expires: <br /> Notary Public <br /> KARLA NICHOLS <br /> NOTARY PUBLIC-STATE OF COLORADO <br /> NOTARY ID 19974015323 <br /> MY COMMISSION EXPIRES DEC 22, 202� ° <br />