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CERTIFICATION <br /> The Applicant, Ames Construction, Inc. (print applicant/company name), <br /> by Trent Irick (print representative's name), as Regional Vice President (print <br /> representative's title), does hereby certify that Poudre Valley REA (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 Burnham Property Borrow (operation name), <br /> File Number M_2021_019 <br /> This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its <br /> authority tinder 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 /> ACKNOWLEGED BY: —�-- <br /> Applicant 4m-e-5 �r�TZuCT��N, IN C_ Representative Name I(r-,2,�� <br /> Date ( Zp 2 Title <br /> STATE OF <br /> ss. <br /> COUNTY OF I:�n,4m s ) <br /> The foregoing was acknowledged before me this 1� day of , 20DL, by <br /> 1�rcc�1e� as�l��cr,d� �''�cc�cctc�e�{ of VAme5lnnruc���n�c�c. <br /> r 1 My Commission Expires: <br /> Notary Public <br /> CATHERINE ANN HARRISON <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 19974014716 <br /> My Commission Expires August 21,2021 <br />