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CERTIFICATION <br /> The A lica <br /> pP � (print applicant/company name), <br /> 1 <br /> by " ' print r presenf e' name), as �' - (print <br /> 7 ) 1 1 <br /> representative's title),does hereby certify tha (structure owner) shall <br /> be compensated for any damage from the proposed ing 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 �'�� � �vy (operation name), <br /> File Number M-t-+-t'-`-2.� (��-f N�cp. <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, Designated Mining Operations. <br /> Any alteration or modification to this form shall result in voidin his rm. <br /> NOTARY FOR PERMIT LIC T <br /> ACKNOWLEGED BY: <br /> ApplicanyQ., ,,f Repres >v amp <br /> Date Tit { <br /> STATE OFP "��-' ) a i ,� N�� - C ' 1 t t <br /> ) ss. M tf—P <br /> COUNTY OF� ) <br /> The foregoing was acknowledged befi6re me this10_-day of er, , 20-L.�,b <br /> as of ly«P , � ✓���t/ .dL <br /> My Commission Expires: /,� <br /> Notary Public <br /> ►(ARIALj9974015323 <br /> NOTARY PUBLIC- ORADO <br /> NOTARY IDMY COMM►SSION 2,2022 <br />