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CERTIFICATION <br /> The Applicant, <br /> b (print applicant/company name}, <br /> Y (print representative's name)7 , as Owners <br /> representative's title) does hereby certify that 1 / - - -- __(print <br /> ' y Y �1QC�c � (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 /> Pettit Application for Spotted Burro Pit <br /> File Number M-19�1 2 -- (operation name), <br /> This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its <br /> aathority under the Colorado Land Reclamation Act for the Extraction of Construction Materials and <br /> the C'olurarlu Alined Land Reclamation Act for gird Rock,Metal and Designated Mining Operutiun,� <br /> Any alteration or ntod f�.ation to this form shall a It in voiding this form <br /> f . <br /> rt,pt N''O RV RMIT APPLICANT <br /> ACKNOWLEGED Y;, <br /> Applicant Representative Name �e l , /`C.c' r c, <br /> Date (S 1171. .?,� <br /> Title tniq-ry!,ke� <br /> C111— <br /> STATE OF__Cd ) <br /> COUNTY OF ) ss. <br /> 7'I foregoing was acknowledged before me thisday of 20 b <br /> as <br /> Y <br /> Not publi MY Commission Expires; <br /> ,2 <br /> TAMMY VIDMAR <br /> Not Pub�liNOTARY PURR <br /> SNE OF COIORADO <br /> MMMY 82W46"M <br />