Laserfiche WebLink
CERTIFICATION <br /> The Applicant, A c Lt (print applicant/company name), <br /> by ,�p�, �/o, 5 (print representative's name), as © /,trGwn (print <br /> representative's title), does hereby certify that a �,;?�/�k4§tructure 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 �V�S 6� (operation name), <br /> 09 File Number M- -At. <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: <br /> Applicant •�. ,,�k� f',�� � Representative Name _ <br /> Date Title f w✓� �� <br /> STATE OF <br /> )ss. <br /> COUNTY OF C.�, S17eh ) <br /> The foregoing was acknowledged before me this day of Alt <br /> ,20 , by <br /> as i\ PT of ft , rJI ca L� a f a]Aw v cE Y-ca <br /> c <br /> My Commission Expires: I <br /> No blic <br /> - - - - - - - - - - - - - <br /> PHYLLIS WILSON <br /> NOTARY PUBLIC•STATE OF COLORADO <br /> NOTARY ID 20204032630 <br /> MY COMMISSION EXPIRES SEP 18,2024 <br />