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CERTIFICATION <br /> The Applicant, Grand Junction Pipe & Supply Co,represented by Russ Larsen, as President, <br /> does hereby certify that the Frazier Richard M Revocable Trust (structure owner) shall <br /> be compensated for any damage from the proposed mining operation to the above listed <br /> structure(s) located on or within 200 feet of the proposed affected area described within <br /> Exhibit A,of the Colorado Mined Land Reclamation Board Reclamation Permit Application <br /> for the Delta Paving Gravel Pit. <br /> This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its authority under <br /> the Colorado Land Reclamation Act for the Extraction of Construction Materials and the Colorado Mined Land <br /> Reclamation Act for Hard Rock,Metal, and Designated Mining Operations.Any alteration or modification to <br /> this form shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> Applicant(-.�a•��� Su.�cT,'oj PrPF Representative Name ��..aSSf/( LA.esfAJ <br /> Date Ks r 3t f', a 0 D Title I'�Fs, a2vT <br /> STATE OFO-L L. a c< i ) <br /> )ss. <br /> COUNTY OF((\� c` ) <br /> The foregoing was acknowledged before me this y1 day of�;`� u; ,20" by <br /> _ , r <br /> as (`G' of <br /> Ad My Commission Expires: <br /> Notary ublic <br /> CRYSTAL LAKE <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20194003813 <br /> MY COMMISSION EXPIRES JANUARY 28,2023 <br /> 2 <br />