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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- 2021- 021 <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 s-�k- � c' Repres a <br /> Date 6* Title ��b =,-s <br /> STATE OF o ) KYMBERLY J METCALF <br /> NOTARY PUBLIC <br /> ss. State of Colorado <br /> COUNTY OF4 ) Notary ID#20194034257 <br /> My Commission Expires 09/06/2023 <br /> The for oing was acknowledged before me this day of 20 t- , by <br /> as of jo�{tiw <br /> My Commission Expires: <br /> No ry Public <br />