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CERTIFICATION <br /> The Applicant, Fwrvont Paving&Redl-Mix (print applicant/company name), <br /> by John Paul Ary (print representative's name),asPOWent (print <br /> representative's tide),does hereby certify that Black HOW Energy (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 Two Rivers Pit (operation name), <br /> File Number M-19"-OW. <br /> Thk form has been approved by the Colorado Mixed Land Reclamation Board pursuant to its <br /> authod&undo the Cokrado Land Reclamation Act for the F.xtrladian of Coxstrudlwr Materhris and <br /> the Colorado Mined Land Reclamation Act for Hard Rock,Metal,and Designated Mixing Operation& <br /> Any ahlemdon or mod j Wdon to this form shall result in voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNO EG D <br /> Applicant Representative Name fJ�X* P <br /> Date _ �p 3 Title Oi._'___4�A o t_ <br /> STATE OF <br /> ss. <br /> COUNTY OF;;MIA be. ) <br /> The foregoin was acknowledged kfibre me this day of ,20_43 by <br /> Ari �_as of Fvms.d ,o1eLl <br /> � �- My Commission Expires:_[i <br /> l0 tic <br /> JODI D SCHREIBER <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> i NOTARY ID 20064001792 <br /> PJIY COMMISSION EXPIRES OCTOBER 6,2022 <br />