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CERTIFICATION <br /> The A plicant, 4 (print applicant/company name), <br /> 69 r rint representative's name), as /q��er (print <br /> repres�ntafive's title),does hereby certify that 6 rJ1 G�1 �y (structure owner)shall <br /> be compensated for any damage from the proposed mining operation to the above listed structure(s) <br /> 1 <br /> located on or within 200 feet of the proposed affected area described within Exhibit A,of the Reclamation <br /> I <br /> Permit Application for �1 (V'er (operation name), <br /> File Number M-I qft-� <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 /> ACKNOWLEGEQD BY: <br /> -X Applicant ' ` Q �' Representative Name <br /> Date g 12 4�2- Title�T( <br /> STATE OF (o t^0.ko ) <br /> )88. <br /> COUNTY OF Ifro 6rako ) <br /> i <br /> e foregoin was acknowledged before me this � day of b ,20 Z�by <br /> in S. r as A h of. "T L L-G <br /> My Commission Expires: D 3 • O I • .14-e <br /> Public <br /> JESSICA FRANKS <br /> Notary Public <br /> State of Colorado <br /> Notary ID#20224008561 <br /> My Commission Expires 03-01-2026 <br />