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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 Western Midstream —(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 shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> Applicant6,} Representative Name <br /> Date 1 /12-/Z 3 Title ti,Jct k,- <br /> STATE OF <br /> ss. <br /> COUNTY OF3ro I� ) <br /> The foregoing was acknowledged before me this Z day of -Fa�V-1 20 �3 by <br /> /t , c t b in _as Wa:k(P shL(t5/�ytQ'C(of -� -C - 0 L <br /> My Commission Expires: C/c-Ua 1 L1,_2O Zj <br /> �otary Public <br /> CATHERINE HARRIS <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20214005321 <br /> MY COMMISSION EXPIRES FE13RUARY 9,2025 <br />