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CERTIFICATION <br /> The Applicant, �ri f Ledi (Wiy , Int. (print applicant/company name), <br /> (print resentativve"'s name), as +�.J c�.11�r (print <br /> representative's title), does hereby certify that Luc Vtyxi� 1 (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 - Ir- (operation name), <br /> File Number M- - <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 /> ACKNOWLE I:t, <br /> ApplicantRepresentative Name P. A7K_4 <br /> Date � Title P—eddsA-r- <br /> tSTATE OF <br /> ss. <br /> COUNTY OF t'k a '' ) <br /> The forego was acknowledged be ore me this /IS day of , 20v , by <br /> —1 l�L as alj. of �X � q c . <br /> My Commission Expires: 6 4 <br /> No Public <br /> ENOTARY <br /> DI 0 SCHREIBER <br /> OTARY PUBLIC <br /> TE OF COLORADO <br /> ID 20064001792 <br /> N EXPIRES OCTOBE:6,20221 <br />