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CERTIFICATION <br /> The Applicant, Gregg Morrill,as Owner, does hereby certiR that the Department of <br /> Transportation(structure owner) shall be compensated for any damage from the proposed mining <br /> operation to the above listed structure(s) located on or within 200 feet of the proposed affected <br /> area described within Exhibit A. of the Reclamation Permit Application for the Bancroft Placer <br /> Mine, File Number M-2020-025. <br /> This form has been approved fi=the Colorado alined Land Reclamation Board pursuant to its authorio�under the <br /> Colorado Land Reclamation Act for the Extraction of Construction Alaterials and the Colorado Mined Land <br /> Reclamation.4ci for Hard Rock Metal. and Designated Ah tine Operations. Ain alteration or modification to this <br /> form shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> n t <br /> Applicant _ y,✓Y�- z'u Representative Name <br /> Date _6� -L.*3^2 a 1 Title __.-- <br /> STATE OF _ _CC. ) <br /> ss. <br /> COUNTY OF�� A <br /> The foregoing was acknowledged before me this )3day of ) 0 . 2020 by <br /> C ( Of <br /> 1.'tX,•ar'k"f�"`'tt _� `/rt,�'}�' <br /> _! My Commission Expires: -L& alit � <br /> Notary Public <br /> ERIN STAATS <br /> NOTARY PUBLIC <br /> STATE OF COLORApC; <br /> 4OTARY It?#2019�40320e3 <br />