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CERTIFICATION <br /> The Applicant, M n it ,'\\ n g 1 Cx rQ (print applicant/company name), <br /> by o�1 �y47! (print representative's name), as lA.�h,vo_(- (print <br /> representative's title), does hereby certify that LAA structure owner) shall <br /> be compensated for any damage from the proposed mining operation to the a ve listed structure(s) <br /> Iocated on or within 200 feet of the proposed affected area described within Exhibit A, of the Reclamation <br /> Permit Application for _ L- j o thS Pr + (operation name), <br /> File Number M-jQL--PA. <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,Metals 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 e!jI.. l�,�� �'' Representative Name dP <br /> Date S-14211 I _Title <br /> STATE OF C ) <br /> ss. <br /> COUNTY OF CP f ) <br /> The forego in ego was acknowledged before me this �L% day of C� 20 d b <br /> %A n h q as t) Ip V- Of A A X <br /> OL <br /> My Commission Expires: <br /> Notary <br />