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CERTIFICATION <br /> The Applicant, SE-%SE-% c c..T , \-1 ( (print applicant/company name), <br /> by '1.< ' I (print representative's name),as ty+ (print <br /> representative's title),does hereby certify that Le111, - { (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 —IN- j�,r.���y C-4-Al r-,Nz- (operation name), <br /> File Number M-$l -3i . <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 /> Applicant Representative Name <br /> Date 41' - 117 Title <br /> STATE OF__66atak ) <br /> )ss. <br /> COUNTY OF Cs. — ) <br /> The foregoing was acknowledged before me this 7 day of n ri ,20/'7,by <br /> 1�a°tl leacA as CGOne✓ of eI4'—f 6121-e PrisCSt LL <br /> „ My Commission Expires: 2 <br /> I f Diq <br /> Notary Public �� <br /> SHAWN LOUISE WISE <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20154018217 <br /> MY COMMISSION EXPIRES MAY 7,2019 ,\ <br />