Laserfiche WebLink
CERTIFICATION <br /> The Applicant, Il`c'fv k ' Ke� ; i tA Q Q. (print applicanticompany name), <br /> by ....Nilo.. P. Y T(Pnnlh resentative'a name),as PrP 514 ►, _-.-- (print <br /> representative's title),does hereby certify that 1K,,,rx1 T.rN a OnaM Q__(structure owner)shall <br /> be compensated for any damage from the proposed mining operation to the above listed structuue(s) <br /> located on or within 200 feet of the proposed affected arca described within Exhibit A,of the Reclamation <br /> Permit Application for t �_� K.. 1}- (operation name), <br /> File Number M- - EQ. <br /> This form has been approved by the Colorado Mined Land Recdanation Board pursuant to its <br /> authority under the Colorado Land Reclamation Ad for the Extraction of Construction Materials and <br /> the Colorado Mined Land Reclamation Ad for Hard Rock,Metal,and Designated Mining Operation& <br /> Any alteration or modification to this form shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> . 1„,. <br /> Applicant k rnr, -1 . tot Representative Name \1111111ka,,,,,,• <br /> Date t at l{+a-o ere Title I r t j <br /> STATE OF i•I o,A,L1,13 ) <br /> )ss. <br /> COUNTY OF t`}Y i 1��tr ) <br /> The foregoingwas acknowledg beforeinc this I h: ay of y�Ft►u u�tt i ,20..4,^7 <br /> 1 85715-1 of1�thMft <br /> ►�. ' K � n +� <br /> • <br /> t ( _. ,(i'�� My Commission Expires: /0/it/ <br /> Nqc <br /> JO0'C SCkREIBER ' '- <br /> NOTARYFUCK <br /> STATE OF CC 1..) A:.1) <br /> TAR'r :1 R)i gJor)1'42 <br /> Rt. r;Jura16,S1;.NExr.RES.:Ci08ER6 :0<:{ <br />