Laserfiche WebLink
CERTIFICATION <br /> The Applicant, Caerus Cross Timbers LLC (print applicant/company name), <br /> by Dave Bowers (print representative's name), as Colony Shale Oil Project Manager(print <br /> representative's title), does hereby certify that NSA (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 Colony Shale Oil Project (operation name), <br /> File Number M-1980-047 . <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 /> ACKNO E ED <br /> Applicant V 1 LL(Representative Name �( 1 <br /> Date d/�� Title we SALE OIL�I$11C� 11 <br /> STATE OF r4,gracko ) <br /> ss. <br /> COUNTY OF Gay ) <br /> r— <br /> The foregoing was acknowledged before me thi day of J` ,20C ,by <br /> "g S as Cb iett ofCq Ctross <br /> Maw <br /> My Commission Expires: p1b o�LOC�S <br /> Notary Public <br /> FR CISCO JIMENEZ <br /> Notary Public <br /> State of Colorado <br /> Notary ID#20094012882 <br /> My Commission Expires 04-20-2025 <br />