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CERTIFICATION <br /> The Applicant, City and County of Broomfield ____(print applicant/company name), <br /> by Brennan Mlddleton (print representative's name), as Water Resources Manager (print <br /> representative's title), does hereby certify that Centuryl-ink _ _ (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 forth shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: � <br /> Applicant6L�71- (bnA- ('>- " kr Kf epresentative Name <br /> Date /1Z(Z3 Title t.Jc- V�-"c. --u> <br /> STATE OF <br /> ss. <br /> COUNTY OFEQo g )�- ) <br /> The foregoing was acknowledged before me this )2 day of 10.�1Ja( , 20 13, by <br /> 41/'L'Mx­(o My Commission Expires: kUQ� �� 2DZS <br /> aotary Public <br /> CATHERINE HARRIS <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20214005321 <br /> RUARY 9,205 <br /> MY COMMISSION EXPIRES FEB <br />