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CERTIFICATION <br /> The Applicant, General Shale Brick, Inc. (print applicant/company name), <br /> by Harold Stickler (print representative's name), as Plant Manager (print <br /> representative's title), does hereby certify that Colorado State Land Board (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 Dawson Mine (operation name), <br /> File Number M-1977 392 <br /> This farm has been approved by the Colorado Mined Land Reclamation Board pursuant to its <br /> authoritf,tinder the Colorado Laud Reclamation Act for the Extraction of Construction Materials and <br /> the Colorado Mined Land Reclamation Act fur Hard Rock,Metal, and Designated Mining Operations. <br /> Any alteration or„todiftcation to this form shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEG ' BK <br /> Applicant Representative Name <br /> Date J Title P LA t1t1.7 i��t <br /> STATE OF ) <br /> ss. <br /> COUNTY OF Ada <br /> lie fort ', 4 ova knowledge fore me this day of <br /> (2p� as rn <br /> s <br /> t My Commission Expires: 2Q22 <br /> Notary Public <br /> MELISSA E HERNANDEZ <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 19954007940 <br /> MY COMMISSION EXPIRES APRIL 7.2022 <br />