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CERTIFICATION <br /> The Applicant, ��5�-�(���'j e� . 111�(_• (print applicant/company name), <br /> byY[�(Q�-�- �,�c�uf� (print representative's name), as '���(,(, �rl�SiG(eJ')t (print <br /> representative's title), does hereby certify that ��q�1j�-t K�}-� (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�S}-�� p;k (operation name), <br /> File Number M-�j_- o��. <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 /> Applicant �"S"/� �2'��''`''KJ Representative Name� lG�i�st,��y�`-' <br /> I <br /> Date ,���Z�2� Title �� <br /> STATE OF L���o ) <br /> ) ss. <br /> COUNTY OF A��2�cas� ) <br /> The foregoing was acknowledged before me this av day of � �•�(r�.' 202� , by <br /> /��/,( ►'Kd,�ic�rf' as Yile �nss,�r.��� c: ltlS Gc�-r��ie�J �i�- <br /> —_t y__— <br /> c,.�• My Commission Expires: S�a?9�.20�� <br /> otary Public <br /> THERESA L GARCIA <br /> NOTARY PUBLfC <br /> STATE OF COLORADO <br /> NOTARY ID 19984017165 <br /> MY C�MMISStON�XPIRES 08/29l2021 <br /> a_�� <br />