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CERTIFICATION <br /> The Applicant, City and County of Broomfield _(print applicant/company name), <br /> by Brennan Middleton (print representative's name), as Water Resources Manager (print <br /> representative's title), does hereby certify that Fort Lupton Public Works _(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 Heit Pit Resource _ (operation name), <br /> File Number M-2003.016 <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 shalt result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: I <br /> Applicant Ci�y Ce►��:1 `Representative Name <br /> �c,�.•a-t,lM„ololCo ;��__ <br /> Date 1 12-(Z Title_ v.J G(k� aq e� <br /> STATE OF0/or jr) ) <br /> ss. <br /> COUNTY OF�&Qtm�e <br /> The foregoing was acknowledged before me this12- day of]--�Y)oaf_ _ 20 23, by <br /> ��-�����'1._ �_----as �?S�1Li:C S�lAna�(o f__(��1.� r n� ��"oD►'�'1�j�°l c�-- <br /> _ My Commission Expires: �_�y�^_t <br /> Notary Public <br /> F <br /> ATHERINE HARRISNOTARY PUBLIC <br /> TE OF COLORADOARY ID 20214005321ON EXPIRES FEBRUARY 9,]2025 <br />