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CERTIFICATION <br /> The Applicant, �'1 C� �p � (print applicant/company name), <br /> i LYL�G.• c�_ �, S v �(CG�1 .. <br /> by E-4 L. (print representative's name), as (print <br /> representative's title), does hereby certify that�5CC,.,R ,, ta-r- ,->e:� �� ,.It'Kstructure 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 ., Lzd (operation name), <br /> File Number M-,9D1L- U <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 j/'' i�' Representative Name ..�— <br /> Date L' - 20' -2j Title V� <br /> STATE OF C C 'OA b ) <br /> ) ss. <br /> COUNTY OF C U 4 (-� ) <br /> The foregoing was acknowledged before me this day of d i , 2002), by 11` <br /> as i,3 {gyp t- of /YA �� �cx-? �Pl co, <br /> My Commission Expires:�_� j C�doy <br /> Nota u lic <br /> PHYLLIS WILSON <br /> NOTARY PUBLIC-STATE OF COLORADO <br /> NOTARY ID 20204032630 <br /> MY COMMISSION EXPIRES SEP 18,2024 <br />