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CERTIFICATION <br /> The Applicant, orb i (print applicant/company name), <br /> by --JohQ. (print repr tative's name),as 2n fi�At4% (print <br /> representative's title),does hereby certify that IanY iA 1`) QDA r5 (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 �G�S �r.� (operation name), <br /> File Number M- o'►I-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 Rocky Meta4 and Designated Mining Operation& <br /> Any alteration or modification to this form shall result in voiding this form. <br /> NOTARY FOR PFJthW APPLICANT <br /> ACKNOWLEGED BY: <br /> t--- ►�UX� 11C <br /> Applicant PAYiQ, l Representative Name <br /> Date f d� / �, �, Title <br /> STATE OF 0 ) <br /> ss. <br /> COUNTY OF1Y1 <br /> The forego' was aclmowledged efore me this.Zday of 01 b 207 �,by <br /> Ajnd as of aA� <br /> kLct Y <br /> My Commission Expires: 6 (o .)a- <br /> No u lic or W <br /> JODI D SCHREIBER <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20064001792 <br /> MY COMMISSION EXPIRES OCTOBER 6,2022 <br />