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CERTIFICATION <br /> The Applicant, United Companies, Inc. (print applicant/company name), <br /> by P (print representative's name),as 5 I� eG . (print <br /> representative's title),does hereby certify that 1 Q(qrL W-A,tAs (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 Otter Creek Pit expansion (operation name), <br /> File Number Mob - . <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 /> Ilse 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 /> Applicant��/�P� CQ 5. �IT�, Representative Name oe <br /> Date Title '� �•� S< C <br /> STATE OF _(f 0 ) <br /> )ss. <br /> COUNTY OF G� )To foregoing was acknowledged before me thisd/ day of Azlphel—,20�,by <br /> as <br /> ' My Commission Expires: A/-1/ �j 3 <br /> Notary Public j <br /> GENEVIEVE MARIE BLECHA <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID#19914003259 <br /> M Commission EX fires April 4,2023 <br />