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CERTIFICATION <br /> The Ap nt, City of Grand Junction (print applicant/company name), <br /> by print representative's name), as Public Works Director (print <br /> representative's title), does hereby certify that City of Grand Junction Cemetery(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 Riverside Parkway (operation name), <br /> File Number M-2020-038 . <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 resttlt in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> Applicant G�f7-Y �'JGT6=representative Name 1/tie }� <br /> Date &2- Title <br /> STATE OF rolo,JG ) <br /> ss. <br /> COUNTY OFF tc ) <br /> The foregoing was acknowledged before me this <br /> _j�day of � 20 Za,by <br /> Sro..�� 't rest as �1:. �Li��r��t o r of ` C 1° <br /> My Commission Expires: t <br /> otary blic <br /> E <br /> NA M. COSTANZO <br /> OTARY PUBLIC <br /> TE OF COLORADO <br /> RY ID 020124044930 <br /> balm E)OUes July 23,2024 <br />