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CERTIFICATION <br /> The Applicant, Washington Co. Road & Bridge Dist.3 (print applicant/company name), <br /> by Steve Williams (print representative's name), as Road Supervisor (print <br /> representative's title), does hereby certify that 'k&jj4�Snt0f*1kjg4 (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 Nelson Pit (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 40,'Ad 3 Representative Name bird C td:l l;ou D1 <br /> 4YL <br /> Date V����t i'6, ZOZO Title <br /> STATE OF ) <br /> ) ss. <br /> COUNTY OF ofv <br /> The foregoing was acknowledged before me this day of 20,2�, by <br /> of Co. Root h )&-I cl e— <br /> IJ <br /> My Commission Expires: ' )`i - as <br /> Notary Public <br /> MICHELLE LEEANN SWAN <br /> Notary Public <br /> State of Colorado <br /> Notary ID II 20204016873 <br /> M Commission Expires 05-14-2024 <br />