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I <br /> CERTIFiCATION <br /> The ,applicant. Salisbury Gladstone LLC I print applicant/company name), <br /> b, Jeff Carter _ (print representative's name), as Manager (print <br /> representative's title). does hereby certif} that David MOSch _(structure owner) shall <br /> be compensated for anv damage from the proposed mining operation to the above listed structures) <br /> located on or within 200 feet of the proposed affected area described %%ithin Exhibit A.of the Reclamation <br /> Permit Application tor Gladstone Toll Mill (operation name). <br /> File Number M 2020-030 <br /> This form has been appro red he the Colorado ;Mined Land Reclamation Board pursuant to its <br /> authority under the Colorado Land Reclamation Act for the Ewrac•tion of Construction Vate•riuls and <br /> the Colorado dined Land Reclamation Ac•t for Hard Rock, .Metal, and Designated.Minin;; Operations. <br /> Ant'alteration or modification to this firm shall result in voiding this form. <br /> NOTARY NOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> Applicant 1Sbt��fT t•, �k Z Representative Dame r"(t► �� �� <br /> Date 'LZ--Z'g ?O L j lisle �r tdu�f�Cr <br /> STATE OF GD ) <br /> ss. <br /> COUNTY OF EI P4S0 ) <br /> The fore oing %%as acknossledged before me this u day of febAWY 20_4 by <br /> ,TQ—F Cap.frr as ~aa-et of <br /> My Commission Expires: 2,3 <br /> ti - Public <br /> .I6M C"ARUM ETRUSU <br /> NOTARb■UINA <br /> STATE 00 COLORA00 <br /> NOTARY to 301MON000 <br /> MY C0Y 0910N GXP REa A►ML I&tD= <br />