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CERTIFICATION <br /> The Applicant,(1'1 OAorm 1Y..1L Et6 amjicri !(telt I/c (print applicant/company name), <br /> n� Ci � <br /> by YY\O S;�� Crtit 1. (print representative's name), as `m()nOp 4(l rvt1 <br /> p0 (" (print <br /> representative's title), does hereby certify that � ai •L a 4‘ rt ,t 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 m c 60r M P L I (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: / <br /> Applicant I� I'f Jf� I�IIT Representative Name T \ c �C(v MULIC <br /> 'J <br /> Date -a Title r .I10( tnni I \0X1\blejj <br /> STATE OF et-)`Of ") ) <br /> ' �^ ) ss. <br /> COUNTY OF Ek.i ) <br /> The foregoing was acknowledged before me this day of tQ ;c.\ , 202`,-by <br /> t'y\Q_S 1 J 1 to as 1Q }(�,,ijrn�� O`\Yl.`& •tire(Cif) CLI:LH-4 1 c <br /> 6/6C D My Commission Expires: - N - L <br /> Nota Public <br /> JILL MASTERS <br /> Notary Public <br /> State of Colorado <br /> Notary ID#19974010957 <br /> My Commission Expires 06-19-2021 <br />