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CERTIFICATION <br /> The Applicant, Loveland Ready-Mtx Concrete, Inc. (print applicant/company name), <br /> bygrad Fancher (print representative's name),as President (print <br /> representative's title),does hereby certify that C,2 nt a ry Li n V:, LLC (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 Dunn Pit (operation name), <br /> File Number M 2021-059 <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 /> Loveland Ready-Mix ` <br /> Applicant Concrete, Inc. Representative Name / ���' j� -- <br /> Date 2-ram' 'Z Title President <br /> STATE OF O ) <br /> )ss. <br /> COUNTY OF I D-Ak MkA ) <br /> The for going was acknowledged before me this In day of Y 20 by <br /> pl1C�/lQ 12. as of a � <br /> �tnn C My Commission Expires: • '21 LV2� <br /> Nclary Public <br /> JOAN E HORST <br /> Notary Public <br /> State of Colorado <br /> Notary ID N 19944018967 <br /> My Commission Expires 11-21-2u22 <br /> NOTARY FOR STRUCTURE OWNER <br /> ACKNOWLEGED BY: <br /> Structure Owner Name <br /> Date Title <br /> STATE OF ) <br /> )ss. <br /> COUNTY OF ) <br /> The foregoing was acknowledged before me this day of 20 by <br /> as of <br /> My Commission Expires <br /> Notary Public <br />