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CERTIFICATION <br /> The Applicant, CONDOS COUNTY GOVERNMENT (print applicant/company name), <br /> by DON MARTINEZ (print representative's name), asDESIGNEE (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 raider 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 GOVERNMENT Representative Name DON INEZ <br /> Date JUNE 29, 2020 Title ROAD & BRIDGE DIRECTOR <br /> STATE OF cnoRADO ) <br /> ) ss. <br /> COUNTY OF CONEJOS } <br /> The foregoing was acknowledged before me thisg�7 day of , 2048?,-by <br /> ,piP 1 r2- as f .> 1 f?- ofGW <br /> 1 <br /> T My Commission Expires: <br /> of Public <br /> CONSTANCE C RICCI <br /> Notary Public <br /> state of Colorado <br /> Notary I D 0 20044005182 <br /> M commission Ex ires03-07-2024 <br />