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CKRUICATiON <br /> The Applicant, jprint applicant/company name), <br /> by S.�UajA P Ln,� (print rep r tafve's name),as n. _(print <br /> representative's title),does hereby certify that o� trt i-4 t '�`s�u`ct>,r,�owner)shall <br /> be compo nted for any damage from the proposed mining operation to the above listed structure(&) <br /> located on or within 200 feet of the proposed affected area described within Exhibit A,of the Reclamation <br /> Permit Application for {operation namel <br /> File Number M-,jgL1-_L3j <br /> Tots forge has been approved by the Colorado Mined Land Reclamation Ba"pursuant to its <br /> aathor*under die Colorado Land Re dsoeation Ad for the Fx&acdow of Contraction Materials and <br /> the Colorado Mined Land Reclamation Act for Hard Rock,Metal,and Design ded Mining Openadonnas. <br /> Any akersdon or mod i leadon to tote forge shalt result in voiding this farm. <br /> NOTARY FOR F&RWT A P <br /> ACKNOWLEGED BY: <br /> Applicant t 5 1�1 1 Rrliresentative Name <br /> Date aL Title <br /> STATE OF ) <br /> COUNTY OFF)as <br /> The foregoing was acknowledged before me fhiaLLL-dry ofVj 20�,by <br /> —' My commission Expires: <br /> o Public <br /> JODI D SCHREIBER <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20064001792 <br /> MY COMMISSION EXPIRES OCTOBER 6,2022 <br />