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CERTIFICATION <br /> The Applicant, IHC Scott, Inc, (dba Scott Contracting (print applicant/company name), <br /> by (print representative's name), as (print <br /> representative's title), does hereby certify that (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 Rifle Gravel Pit#1 (operation name), <br /> File Number M- - <br /> This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its <br /> authority tinder 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 Representative Name Gn j <br /> Date A Vic, Z�z� Title <br /> STATE OF KYMBERLY J METCALF <br /> SS. NOTARY PUBLIC <br /> State of Colorado <br /> COUNTY OF ) Notary 10#20194034257 <br /> My Commission Expires 09106/2023 <br /> The foregoing was acknowledged before me this(o�day of `' 'S� 20�, by <br /> as \j \c:.Q, of <br /> �J <br /> +� My Commission Expires: /(- <br /> Not Public <br />