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CERTIFICATION <br /> The Applicant, C6 9-� )GAvr vh y ITAX- 010-T- (print applicant/company name), <br /> by 0 H Vqlf.,Aj (print representative's name), as F fD,-jv _ e� (print <br /> representative's title), does hereby certify that Q"-05 C4444�''z''L (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 M a A tj M C� (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 /> ACKNOWLEGED BY: 1 n <br /> Applicant !�' 1 �'` ? } �, Representative Name l C <br /> Date u - Title <br /> STATE OF ) <br /> ) ss. <br /> COUNTY OF <br /> The foregoin was acknowledged before me this day of , 202`, by <br /> as of <br /> Z 64 My Commission Expires: <br /> Notary Public <br /> PATRICIA G. RANOUS <br /> Notary Public <br /> State of Colorado <br /> Notary ID M 20144040457 <br /> My Commission Expires 10-24-2022 <br />