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r � <br /> CERTIFICATION <br /> The Applicant, CONEJOS COUNTY GOVERNMENT (print applicant/company name), <br /> by DON MART I N EZ (print representative's name), as D E S I G N E E (print <br /> representative's title), does hereby certify that (NOT APPLICABLE) (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 GALLEGOS PIT (operation name), <br /> File Number M-1983-164 . <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 CONEJOS COUNTY GOVERNME)S1T Representative Name DON MARILIINEZ <br /> Date JUNE 29,-2020_ Title ROAD & BRIDGE DIRECTOR <br /> STATE OF COLORADO ) <br /> ) ss. <br /> COUNTY OF CONEJOS ) <br /> The foregoing was acknowledged before me thiso day of , 20��by <br /> ,T� as J)a)S On ie-Q_ o <br /> My Commission Expires:,�-?/?I/ <br /> of Public <br /> CONSTANCE C RICCI <br /> Notary Public <br /> State of Colorado <br /> Notary ID#20044006182 <br /> My Commission Ex Tres 03-07-2024 <br />