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CERTIFICATION <br /> The Applicant, '9)V c- S fU'A ����� V�Q-L--- (print applicant/company name), <br /> by U t 5 IeL.- (print representative's name), as (print <br /> representative's title), does hereby certify that V�\QL�,r (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 w (operation name), <br /> File Number M-J y`j-_Cj5. <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 "h 5-r--ie— C o Representative Name I3 c,--v <br /> Date 3 Title <br /> BRANDIJOHNSON <br /> STATE OF C9JOo -CAD ) NOIARY PUBLIC <br /> STATE OF COLORADO <br /> ) ss. NOTARY ID 20194046280 <br /> MY COMMISSION EXPIRES DECEMBER 12,2023 <br /> COUNTY OF ICL�LA ) <br /> The foregoing was acknowledged before me this day of , 20 ,by <br /> 0.D opt A c�v�. as MO A— of 11� <br /> L) <br /> ` My Commission Expires: <br /> Notary Public <br />