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CERTIFICATION <br />The Applicant, <br />" &Y S�Md ies InC. (print applicant/company name), <br />by N Qf (1 W��ch e F�' (print representative's name), as V C(, PY'tS 1, Mt- (print <br />representative's title), does hereby certify that WMCAjA K45qr (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 - J); k (operation name), <br />File Number M-,'bai- 02i"1. <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 �y V'04-60 Representative NameVW <br />Date -Kz�t Title <br />STATE OF 11) 1WW10 <br />COUNTY OF 4404o52 <br />ss. <br />l% <br />The foregoing was acknowledged '/before me this 20 day of /ems(' , 20 2-1 , by <br />as rlCe �ncs,.a�r•�� of .77e- <br />�. My Commission Expires: Sla?9/,2d�� <br />otary Public <br />FTHERESA L GARCIA <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />NOTARY ID 19984017165 <br />COMMISSION EXPIRES 08/29l2022 <br />