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CERTIFICATION <br /> The Applicant, Grm 1 P(Ik (print applicant/company name), <br /> by�! y ("QS M C"ft&print representative's name), a��s��`(1(1(1nry} ,fin, ��- Q [C (print <br /> representative's title), does hereby certify that am 0 C -f oYLo rry Wm"Inastructure 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 I I ► }r(Yl �,1� Pj+ (operation name), <br /> File Number M- - <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:ApplicantAnaIdT/`Representative Name e S MC(V ma <br /> Date Title Y`�Q►'t�t t nTM e on ule' <br /> STATE OFj <br /> ss. <br /> COUNTY OF Qf l ) <br /> The foregoing was acknowledged before me thisz day of i-Q , 20 ,b <br /> `�r►MQ-5, 9 ►((W, A as of%VWYl,i %-iLd CI-L& V- <br /> My Commission Expires: <br /> Nota Public <br /> JILL MASTERS <br /> Notery Public <br /> state of Colorado <br /> Notary ID#19974010957 <br /> My Commission Expires 06-19-2021 <br />