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rrrnt <br /> CERTIFICATION <br /> The Applica (print applicant/company name), <br /> by �+WPIIIW��qDrirt­ presen 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 a above listed str`ucture(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-Mak 426 �� � - � � AcaD. <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 orm. �--� <br /> 1 � <br /> q= � <br /> NOTARY FOR PERMIT APP ,IC T <br /> ACKNOWLEGED BY: -` <br /> t <br /> ApplicanfQ�_C Representative <br /> Date f �— I�f Title .4046.'ar Lv <br /> STATE Old ) �� �f4M i <br /> �6 r-T <br /> ss. <br /> � <br /> M <br /> COUNTY OF <br /> The foregoing was acknowledged before me this ? i�day of 201?, by <br /> >'l�_ res asna ., er of fly C'r��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 22,2022 ; <br />