2020-06-23_REVISION - M1995005

• Permit No: M1995005
• IBM Index Class Name: Revision
• Doc Date: 6/23/2020
• Doc Name: Adequacy Review Response
• From: River City Consultants
• To: DRMS
• Type & Sequence: SO1
• Email Name: ACY
• Email Name: THM
• Media Type: D
• Archive: No

CERTIFICATION
The Applicant, MESA AGG LLC (print applicant/company name),
by DAVID FORENZA (print representative's name), as.MANAGING MEMBER r
............................................................... mm,,,,,,,,,,,,,,,,,,,,,,,,, ......................................................................................................................_.. .............................................(p
representative's title), does hereby certify that NONE (structure owner) shall
be compensated for any damage from the proposed mining operation to the above listed structure(s)
located on or within 200 feet of the proposed affected area described within Exhibit A, of the Reclamation
Permit Application for ORCHARD MESA AGGREGATE
11 ................................. __ _....._ (operation name),
File Number M-1995-005
This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its
authority under the Colorado Land Reclamation Act for the Extraction of Construction Materials and
the Colorado Mined Land Reclamation Act for Hard Rock, Metal, and Designated Mining Operations.
Any alteration or modification to this form shall result in voiding this form.
NOTARY FOR PERMIT APPLICANT
ACKNOWLEGED BY:
Applicant MESA AGG LLC Representative Name
Date �° Title MANAGI
STATE OF 16DMEMB
Y' A }
COUNTY OF� A. ss.
nj 4,
g g his day of
he fore o� was acknowledged
as ��e met � of
SeesMy Commission Expires:
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Notary Pu tic
TRACY A. STATES
NOTARY PUBLIC
STATE OF COLORADO
NOTARY ID#20064045541
i1Ay Commission Expires November 6,2022