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CERTIFICATION <br /> The Applicant, �UC��YJI�� L L <br /> Q 1 (Print applicant/company name), <br /> by e6ccn,., 1(-C-t I(print representative's name), as Owners (print <br /> representative's title), does hereby certify that Chuc� & ( OS bv,�^(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 Spotted Burro Pit (operation name), <br /> File Number M-19 -77 <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 /> ACKNOWLEG D BY: /I <br /> Applicant C,(( Representative Name <br /> Date �(��lL/� Title VYI <br /> STATE OFF ) <br /> ss. <br /> COUNTY OF �O ) <br /> e foreg 'rig was acknowledged before me this day of s , 20s , by <br /> ( as tNQUbejc of C <br /> My Commission Expires: <br /> Notary Public - <br /> REBEKAH H.WOLKING <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20184005385 <br /> My Commission Expires 02-01-2022 <br />