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O _ l6 <br /> WA -t --1`� <br /> fwlreoo <br /> CepoV6f6w " <br /> CERTIFICATION <br /> The Applica , I (print applicandcbmpany name), <br /> by, V u An- <br /> rint presenfafive's name), as I CLA"'r (print <br /> re resentative's title), does hereby certify that`� � <br /> (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 Exhibit A, of the Reclamation <br /> Permit Application for it-) (operation name), <br /> File Number M- <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 APPLIC <br /> ACKNOWLEGED BY: <br /> ApplicanfQ . C� 0 Representative <br /> Date Title Atj k-al oLJ <br /> STATE OFVLCf ) `�. � 9A� �r 6�. r-T I <br /> ) ss. An F-0 <br /> COUNTY OF 0 <br /> The foregoing was acknowledged before me this 9 day of CW/ ;1!e , 201� by <br /> as of �r �� �L� <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 />