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CERTIFICATION <br /> The Applicant, Loveland Ready-Mi), Concrete, Inc. (print applicant/companyname), <br /> by Brad Foncher (print representative's name),as President (print <br /> representative's title),does hereby certify that Ntad Russian Golf Cuurse(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 D u n n P I t (operation name), <br /> File Number M 2021-05 9. <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 <br /> Date ;'-/(-,-Z Z Title President <br /> STATE OF CU�OY'i7_h ) <br /> )ss. <br /> COUNTY OF ACN\Mi`A ) rr II-- <br /> The foregoing was acknowledged before me this Q day of C c6r__ 12 <br /> F-)r a F CuN�V_As R eS* of <br /> ,Mpn L kLq± My Commission Expires. -2- <br /> NotAry Public <br /> JOAN E HORST <br /> Notary Public <br /> State of Colorado <br /> Notary ID 0 19944018967 <br /> My Commission Expires 11-21-2022 <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 />