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q-ce� Wro ,q ,19 <br /> rffGD <br /> opsi4f xorn V Vf6 to 1), ►,i i� <br /> CERTIFICATION 1 <br /> The Applica A(' (print applicant/cpmpany name), <br /> by i �' print presentative s name), as -rl (print <br /> representative's title), does hereby certify that C4K , c_(e ucture owner) shall <br /> mi be compensated for any damage from the proposed nin o e tioWMCL7 above listed structure(s) <br /> located on or within 200 feet of the proposed affected area desccriibed`!within Exhibit A, of the Reclamation <br /> Permit Application for �6*1 QUAI t 7 (operation name), <br /> File Number M- �I � ,�-r <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 APPLICANT <br /> ACKNOWLEGED BY: <br /> Applicanva,g—C�K 0� Repres e J <br /> Date Title M kot,3 <br /> STATE OFPOLZ 1 61"1 coil rT I - I <br /> ss. IVl <br /> COUNTY OF " <br /> The foregoing was acknowledged before me this <br /> day of , 20 by <br /> es as y'J of - / L <br /> Je�e� My Commission Expires: v2 - <br /> Notary Public <br /> LNOTARY <br /> NICHOLS <br /> -STATE OF COLORADO gID 19974015323 2022N EXPIRES DEC 2Z, <br />