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w <br /> CERTIFICATION <br /> The A plicant, QQ IT <br /> (print applicant/company name), <br /> by � Ike r riot representative's name),as &tA A jer (pit <br /> representative's title),does hereby certify that`✓� �ll�awt oftalo a-a�'` _(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 ofthe proposed affected area described within Exhibit A,of the Reclamation <br /> Permit Application for It)h f Yam- t11✓ S~� / (operation name), <br /> File Number M-LVL-jL0j. <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 /> Applicant I—C- Representative Name <br /> Date �j /U 12,"2-- Title � <br /> STATE OF IO ray do ) <br /> )ss. <br /> COUNTY OF -Rk'QRUA e-b) <br /> T foregoing was acknowledged before me this_�'day of btr ,202?,by <br /> rLi rc� as a- of !R iz y a C <br /> CGt� My Commission Expires: 3 D f .10�L <br /> Nt Public <br /> JESSICA FRANKS <br /> Notary Public <br /> State of Colorado <br /> Notary ID#20224008561 <br /> My Commission Expires 03-01-2026 <br />