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CE RTI FICATIO.N <br /> The Applicant. Salisbury Gladstone LLC — — (print applicanticompany name). <br /> by Jeff A. Carter (print representative's name).as Manager (print <br /> representative's title),does hereby certify that Xcei Energy (structure owner)shall <br /> N.,competitsated 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 Gladstone Toll Mill (operation name). <br /> File Number M 2=-030 <br /> This form has been approved bt'the Colorado!fined Land Reclamation Roard pursuant to its <br /> authority under the Colorado Land Reclamation Act for the Extraction of Con..,truction aaterials and <br /> the Colorado.lined Land Reclamation Act for Hard Rork, .Metal.and Designated.Mining Operations. <br /> Any alteration or modification to this form%hall result in voiding this form. <br /> NQTA R 1 V OR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> Applicant 5ej 1 i ���� L L(R rescntativc Namc 3 c cc 4 co r t c <br /> Date s. ," 1 � 1 ` Title <br /> STATE OF QL�� ) <br /> )ss. <br /> COUNTY OF�1�SL� ) <br /> The f� owsaknowedged before me this � yof v,ong y <br /> J Q 4rkr as Kq„ac.f _of IS_ r _jam J, k t l e--- <br /> �- My Commission Expires: <br /> ot�ary Public <br /> ANNA ROORtGUE1 <br /> NOTARY PueLic <br /> STATE OF COLORADO <br /> NOTARY 10 201940234M <br /> VV COVAMS340M EXF4RE3 JUNE 9.2022 <br />