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CERTIFICATION <br /> The Applicant, Liv-teni in CM0 (print applicant/company name), <br /> (print representative's name), asLv,� Use- 1�dm't,Q (print <br /> representative's title), does hereby certify that"t. E.<-\ `j 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 fJA e< P-T (operation name), <br /> File Number M- - <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 Ljn=�t\ 0nuh-6U Representative Nam , ' It1� <br /> j <br /> Date Title Lana UU !RA rv1 n"L 41ca c <br /> STATE OF (�6 LprQ,-, ) <br /> ) ss. <br /> COUNTY OF ) <br /> The foregoing was acknowledged before me this day of , 20?2 by <br /> My Commission Expires: <br /> Notary Public <br /> MINDY DUTRO <br /> Notary Public <br /> state of Colorado <br /> Notary ID#20134026866 <br /> My Commission Expires 04-30-2025 <br />