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CERTIFICATION <br /> The Applicant, Fremont Paving and Redi-Mix, Inc. (print applicant/company name), <br /> by John P. Ary (print representative's name), as President (print <br /> Southeast Colorado Power Association structure owner shall <br /> representative's title),does hereby certify that ( ) <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 Kiowa County Pit (operation name), <br /> File Number M- - <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 /> ACKNOWLE B ((�� <br /> Applicant Representative Name �p1i�n "r. Y1a <br /> Date YTitle a-Q.xi <br /> STATE OF- <br /> ss. <br /> COUNTY OF ) <br /> The foregoin was acknowledged before me this q!Fday of YY1.0.lrl�i , 20_Q3, by <br /> �1Q�Ly1 —as Y'elsl&l yrSC of .-q t S <br /> My Commission Expires: 6tp 4T.Up <br /> Nota P lic <br /> JODI D SCHREIBER <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 200640017k <br /> MY CO&WISSION EXPIRES OCTOBER 6,2026 <br />