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CERTIFICATION <br /> The Applicant, Scott Contracting (print applicant/company name), <br /> by Tony Roberts (print representative's name), as (print <br /> representative's title), does hereby certify that (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 Rifle Pit#1 (operation name), <br /> File Number M- - <br /> This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its <br /> aulhorit)�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 /> Anv alteration or modification to this form shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> Applicant Scott Contracting Representative Name Tony Roberts <br /> Date Title <br /> I <br /> STATE OF <br /> ss. <br /> COUNTY OF <br /> The foregoing was acknowledged before me this , "` -dad of ;, 20 y, by <br /> Tony Roberts as ,, „,,,,; of Scott Contracting <br /> My Commission Expires: f <br /> Notary Public <br /> I�RR1 PRIDAY <br /> NOTARY PUBLIC <br /> STATE(N�()OI,p <br /> NOTAxV TO 19MM10 <br /> �'C�fJSS1oh' -,�: u <br /> ES IAIVII'4RY 4 M3 <br />