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CERTIFICATION <br /> The Applicant, Grand Island Resources, LLC (print applicant/company name), <br /> by Daniel Takami (print representative's name), as Senior executive vice president (print <br /> representative's title), does hereby certify that Grand Island Resources, LLC (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 Grand Island Resources, LLC (operation name), <br /> File Number M- 197.-410. <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 Grand island Resources,LLC Representative Name Daniel Takami <br /> Date Iv `eCX VZ� Title Senior executive vice president <br /> STATE OF V-Q( C9) <br /> ) ss. <br /> D <br /> COUNTY OF `"C .{)(S1 Y)) <br /> The foregoin was acknowledged before me this day of J c1. , 2020, by <br /> iJ�\- 1 -iC p� as r�',�Y �xrc 7 l/f of CAAA,t� ti.- ►.► 01 Id saurcCS <br /> i <br /> �I., My Commission Expires a 4 D ) 2 3 <br /> Notary Ai <br /> co 1D l6195z7 <br /> a�;;`��tawwlyll�,i <br /> � �. F9 <br /> LI Pp ,,'� <br /> �.s�p1ARY •' <br /> . Pue <br />