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CERTIFICATION <br /> The Applicant, General Shale Brick, Inc. (print applicant/company name), <br /> by Harold Stickler (print representative's name), as Plant Manager (print <br /> representative's title), does hereby certify that Colorado State Land Board (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 Dawson Mine (operation name), <br /> File Number M-1977_ 392 <br /> This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its <br /> authority 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 /> Any alteration or modification to this form shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEG <br /> Applicant Representative Name <br /> Date 61 Title PLA&)T MAAA66r-1— <br /> STATE OF 066 ) <br /> ss. <br /> COUNTY OF ) '/ <br /> he fore ww knowledge fore meyt�his day of tbt 1 , b <br /> as v� [�TZ of ha ' J �U►G <br /> r My Commission Expires: 12d2__ <br /> Notary Public <br /> MELISSA E HERNANDEZ <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 1995400794C <br /> MY COMMISSION EXPIRES APRIL 7,2022 <br />