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24125 CR 42 <br /> 4MCMGANDUCAVATIONSC. LaSalle,CO 80645 <br /> 970-378-7000 <br /> NOTARY FOR STRUCTURE OWNER WITHIN 200 FT OF REVENUE <br /> MINE AFFECTED AREA <br /> ACKNOWLEDGED BY: <br /> Structure Owner Representative Name <br /> Date Title <br /> STATE OF Colorado <br /> COUNTY OF ss) <br /> The foregoing was acknowledged before me the_day of 20 by <br /> , as of <br /> My Commission Expires: <br /> Notary Public <br /> 3 <br />