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CERTIFICATION <br /> Brian Brock and-Sheryl Brock <br /> The Applicant, _ (print applicant/company name), <br /> by --------------------------- (print representative's name).as ------------------------------------(print <br /> representative's title), does hereb} certif'v that Black Hills Energy (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 WRC Wet Pit (operation name). <br /> File Number M-2014-063 <br /> This form has been approved bi,the Colorado Mined Land Reclamation Board pursuant to its <br /> authori{y 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 /> ACKNOWL ED BY: <br /> Applicant Representative Name <br /> Date f4arch 22 Title lUj\5 <br /> STATE OF <br /> ss. <br /> COUNTY OF&L P)�On)_ ) <br /> The foregoing was acknowledged before me this—'�, Iday of . 20 . by <br /> My Commission Expires:A&U ZOZZ <br /> Nota• ; ublic <br /> ELIZaABETH KRACHT <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20184020097 <br /> MY COMMISSION EXPIRES MAY 10,2022 <br />