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CERTIFICATION <br /> The Applicant, ro s C'd ns f ' (print applicant/company name), <br /> by S u 16 (print representative's name), as (print <br /> representative's title), does hereby certify that A/c-/1.e- (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 Tom./ IL—f R (operation name), <br /> File Number M-Zct - nab-. <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 /> ACKNOWLEGED BY: Q <br /> Applicant &)UjQ)r V kCS,C Representative Name <br /> Date 4�I� z�� Title 1 Lo S <br /> —r <br /> STATE 01( D <br /> T ss. <br /> COUNTY O _ I ) <br /> e for go' s acknowledged a me this 3. day of 20 by <br /> as t��JVI of V- 6Yt,5 <br /> My Commission Expires: <br /> No ry Public <br /> FN,t.,,y <br /> CY L RAZZANO <br /> blic—State of Colorado <br /> ry ID 19934000126 <br /> ion Expires Jan 29,2021 <br />