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CERTIFICATION �eF-rAcf-6 I ' <br /> The Applican ,4 A (print applicantlompany name), <br /> by print r presenfafive's name), aster �C (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 described within Exhibit A, of the Reclamation <br /> Permit Application for `-� (f10J-0'57>0-Kf cat 7�� (ope>ation name), <br /> File Number M- _q-6L,, -r� +kA574 —. F-AE-Vee -C 00 1W AGO <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 Dest nated Mining Operations. <br /> Any alteration or modification to this form shall result in voiding 's form. <br /> NOTARY FOR PERNII APP I A T <br /> ACKNOWLEGED BY: <br /> Applican 0 (Z Representative <br /> c <br /> Date Title MAIJ I b1,3 <br /> n <br /> STATE OF -�,,L*°� ) � � a PT ) . ►1 <br /> ss. � � <br /> COUNTY OF ) <br /> The foregoing was acknowledged before me this /D-day of 0- 20-1-� by <br /> �il;v�- A 2'�3c�nt'�5 as of �51k <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 22,2121 <br />