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ire,q —1,1 <br /> CERTIFICATION r er---rA a-6 I <br /> The Applicant �1"' (print applicant/company name), <br /> by ' Y �qa �prin r pren ative's name), as �fi -� (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 desccribned` ,within Exhibit A, of the Reclamation <br /> Permit Application for (operation name), <br /> File Number M- � 1 `"� '� � > � - � �► /�c. <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 APP <br /> ACKNOWLEGED BY: <br /> A lican n �-� � � �T pp t'�S—�C�<�I� � , Represent am b P� � <br /> Date �Li .'IE�_ � tle IrI <br /> STATE OF'� ) �� �� Cz ;24 ref ) . I( <br /> ss' PA <br /> COUNTY OF��� ) <br /> The foregoing was acknowledged before me this )0' day of C-!QA.1e, , 201'2, b <br /> as r' of G//r' <br /> Q <br /> - My Commission Expires: 0112-�19- <br /> Notary Public <br /> F <br /> LA NICHOLS <br /> -STATE OF COLORADO <br /> D 19974015323 <br /> EXPIRES DEC 22,2022 <br />