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CERTIFICATION <br /> The Ap licant, ���„� dv 6 Iacer e irlm (print applicant/company name), <br /> by we (print representative's name), as Clam owner- (print <br /> representative's title), does hereby certify that (structure owner) shall <br /> be compensated for any damage from the proposed mining operation <br /> /torathe 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 44-:2 an o 64e--070SOZ (operation name), <br /> File Number M-2W8-oZO. OW4 S 4-2018-D.ZS <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 Representative Name Lar .C-ove <br /> Date e_ Clay.►; owner <br /> STATE O ) <br /> ss. <br /> COUNTY OF ) <br /> T foregoing was acknowledged before me this_ day of„ _ 20?�6 , by <br /> ve as 41in P r of <br /> My Commission Expires: <br /> otary Public <br /> NICOLE DAWN FRANCIS <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20204003105 <br /> MY COMMISSION EXPIRES JANUARY 23,2024 <br />