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CERTIFICATION <br /> The Applicant, +��j�,.-.�r �f�� ��n s' �� (print applicant/company name), <br /> by �;;,�i� ��,,,,�� (print representative's name), as `���.s �� �t-��� (print <br /> representative's title), does hereby certify that nl�>�.� (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 E�iibit A, of the Reclamation <br /> Permit Application for T�../ ��:-r �►� �r (operation name), <br /> File Number M-Z�/ 5 r�-�-. <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 /> . <br /> Applicant__��� �X � k��,�;C'i„��`� Representative Name � � 1�R.,e�l �- �4 W�'� � <br /> Date 6ZI� � Z0� Title �j�f,�S � c?.C.�p �. � � <br /> STATE OF`-���� <br /> ) ss. <br /> COUNTY 0�������-�) <br /> e for goi s acknowledged e me this 3 day of W� � 20� by <br /> ` U7e as ����Nl� of il <br /> � _ �VI�S <br /> c�~ <br /> � My Commission Expires: (�� ��`�''� <br /> No ry Public <br /> STACY l RAZ2AN0 <br /> Notary Public—State of Colorado <br /> Notary ID 1g9340p0126 <br /> My Commiss�on Exp�res Jan 2g,2021 <br />