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CERTIFICATION <br /> TheZAplicant, , � (print applicant/company name), <br /> The i <br /> b e)e r4,U4rint representative's name),as <br /> (print <br /> represt ntative's title),does hereby certify that atcic&tr c- 14.sr! ` (structure owner)shall <br /> be co pensated for any damage from the proposed mining operation to the above listed structure(s) <br /> located on or within 200 feet of theproposed affected area described within Exhibit A,of the Reclamation <br /> Permit Application for k/�i f I� R f ye-r (operation name), <br /> File Number WVL-.!�V- <br /> This form has been approved by the Colorado Maned 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 pp Representative Name -3c� <br /> Date 17-0_(7,2- Title 'd 1�nvp—r <br /> STATE OF 6ro d O ) <br /> )ss. <br /> COUNTY OF Q &A c Q I <br /> �,H I <br /> The foregoing was/acknowledged before me this A day of ,2022,by <br /> �ytn �. &rcj.,.-!2'r�' as h(e s.a~ of � ,G T _Q <br /> jt/-V,� <br /> CA_ My Commission Expire$: 0 3 . O 1 - a o 2 lC <br /> N Public <br /> JESSICA FRANKS <br /> Notary Public <br /> State of Colorado <br /> Notary ID#20224008561 <br /> L <br /> y Commission Expires 03-01-2026 <br />