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PERM ITTEE/STRUCTURE OWNER AGREEMENT <br /> Mine: Native/Pierre Mine-M-1977-321 <br /> State of Colorado, Mined Land Reclamation (MLR) law requires the permit applicant(operator/permittee)to agree <br /> to reimburse the owner of any permanent man-made structure(s)within 200 feet of the permitted mining area, for <br /> damage done to the structure(s) as a result of the permitted operation. <br /> Summit Brick and Tile Co. believes Dorothy M Anaya own the following structure(s), located within 200 feet of the <br /> permitted mining area: House <br /> Summit Brick and Tile Co. agrees to reimburse you for any damage done to the listed structures as a result of the <br /> mining operation. Your acknowledging signature and a notary seal in the spaces provided below shall satisfy the <br /> MLR law requirement. Summit Brick and Tile Company certifies this agreement as follows: <br /> CERTIFICATION: The Applicant Summit Brick and Tile Co. represented by Matthew R. Welte as CEO, does <br /> hereby certify that Dorothy M Anaya shall be compensated for any damage from the proposed mining operation to <br /> the above listed structure(s) located within 200 feet of the permitted mining area described in the MLR Permit for <br /> the Native/Pierre Mine. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEDGED BY: <br /> Permit Applicant: Summit Brick and Tile Co. P.O. Box 533 Pueblo 81002 <br /> Representative: Matthew R. Welte CEO-719-542-8278 <br /> Signature: ' V�� �/ ` �'� Date: �� <br /> STATE OF Colorado ) <br /> ) SS <br /> COUNTY OF Pueblo ) <br /> The foregoing was acknowledged before me this_,-day of 2020, by <br /> Matthew R.Welte as CEO of Summit Brick &Tile CO. <br /> Notary Public �, �.� � My Commission Expires- <br /> KATHLEEN A CLEMENT[ <br /> NOTARY PUBLIC <br /> NOTARY FOR STRUCTURE OWNER STATE OF COLORADO <br /> NOTARY ID 20144043949 <br /> MY COMMISSION EXPIRES NOVEMBER 1 S,2U22 I ACKNOWLEDGED BY: <br /> Structure Owner(s): Qorothy M A a <br /> Signature: f _ Date:� �I�ao ab <br /> STATE OF ) <br /> )ss <br /> COUNTY OF ) <br /> The foregoing was acknowledged before me this day of 20—, by <br /> Notary Public: My Commission Expires: <br /> SENT TO STRUCTURE OWNER VIA CERTIFTED MAIL # 70192970000082391387 <br />