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CERTIFICATION <br /> The A plicant, /��/�Q�i'//� ZZI/ <br /> vleh (print applicant/company name), <br /> by /"/l"G/�C/? (print representative's name), as <�I '✓� (print <br /> representative's title), does hereby certify that�),45hr'n /k ki (structure owner) shall <br /> �vE <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 /> &"0/)Permit Application for �i�d/ X 7/ '�� (operation name), <br /> File Number M-ML/-,07. <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 /> Applicant "1 ,444pl flf �✓�'/J Representative Name 77 it <br /> Date Title 4241- <br /> ��"���� MELISSA RENAE ALBERT <br /> STATE OF�(Z ) NOTARY PUBLIC <br /> STATE OF COLORADO <br /> ) ss. NOTARY 1020204032418 <br /> COUNTY OF L.Ayjs'nk/j/ ) My owwWssion wores September 17,2M4 <br /> The foregoing was acknowledged before me is� day of— , 20- , by <br /> Mph <br /> __as t. �--of <br /> My Commission Expires:_<Gak aZO Zq <br /> N to Public <br />