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� <br /> i <br /> i ' <br /> � NOTARY FOR STRUCTURE OWNER WITHING 200 FEET OF <br /> � REVENUE MINE AFFECTED AREA <br /> ACKNOWLEDGED BY: <br /> Applicant: Representative Name: <br /> Date: Title: <br /> STATE OF ) <br /> ) ss. <br /> COUNTY OF ) <br /> The foregoing was acknowledged before me this day of , 2022 by <br /> as of <br /> My commission expires: <br /> Witness my hand and official seal. <br /> Notary Public <br /> i <br /> 3 <br /> ' 4/8/22.Wr Adj Prop O�merBLUE <br />