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CERTIFICATION <br /> The Applicant, tr ernrck 4 Wl 4 cede aljk/ I h t . (print applicant/company name), <br /> by Lith1 n (print representative's name), as --Preh i aLki- (print <br /> representative's title),does hereby certify that J0 Fj�,Nz U (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 -6-0 ymk cM D yt.. ►.4- (operation name), <br /> File Number M. fie-per. <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 /> � I h u,c, IIS L_. 11111116 <br /> Applicant .'EfYloi& `?�2 vi Representative Name <br /> Date ///IPJ&Dc:)-w., Title '11),20 jid DL <br /> STATE OF JO i- .c) <br /> ) ss. <br /> COUNTY OF `1?'ifSyLf ) <br /> The foregoing was acknowledged bcfore me this day of `..JVIL,[1(4/ ,2 i.• by <br /> P•"' vl as 1 m d of IA: . . A A- 5 t _ ✓hdet <br /> r <br /> ` My Commission Expires: /0 <br /> Notary ' blic <br /> JODI D SCHREIBER <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> 6,2022 <br /> NOTARY ID 20064001792 <br /> MY COMMISSION EXPIRES OCTOBER <br />