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Y <br /> CERTIFICATION <br /> The Applicant, C ` v ✓ V ` LLL (print applicant/company name), <br /> by �f�C(�� (nJ t L�c'1%N(print representative's name), as Manager (print <br /> representative's title), does hereby certify that FOSS; L C Mk M�t-'9,S (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 Upper Gold Links Mine (operation name), <br /> File Number M-2016-083 <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 /> C <br /> Applicant <br /> i ►N �,/� l.� � Representative Name l� <br /> � N Re r <br /> Date �� 1-�22 Title <br /> STATE OF � d ) <br /> r ss. <br /> COUNTY OF l WVA ) <br /> The foregoing was ac wledged beforen�me this 2 da of r��'` , 20 u, by <br /> as Cj�iIJ��U `(. A'f �(if -- lr <br /> My Commission Expires: 1', Z <br /> otary Pub <br /> MORGAN SCHAEFER <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID#20184003986 <br /> toy Commission Expires January 23,2026 <br />