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CERTIFICATION <br /> The Applicant, IHC Scott, Inc. — (print applicant/company name), <br /> by 466kcil (print representative's name),as U("y + res (print <br /> representative's title),does hereby certify that Shane Collett_ (structure owner)shall <br /> be compensated for any damage from the proposed mining operation to the above listed structure(s) <br /> Incated on or within 200 feet of the proposed affected area described within Exhibit A,of the Reclamation <br /> Permit Application for Collett Property Borrow Area _ (operation name), <br /> File Number M-2�n•�g�. <br /> This form has been approved by the Colorado Alined Land Reclamation Board pursuant to its <br /> authority under the Colorado Land Reclamation Art 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 mod ycation to this form shall result in voiding this form. <br /> P10TARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> Applicant IHC Scott, Inc` Representative Name <br /> Date 241`7 _Title <br /> STATE OF ri-I0 ) <br /> )ss. <br /> COUNTY OFAT—�O�—) <br /> The foregoing was ack before me this day of 2013,by <br /> _— as ljftc of IHC soon.Inc <br /> 1 t 2 , My Commission Expires-, <br /> No Public <br /> MITZI RE�ESE <br /> Notary public <br /> State of Colorado <br /> Notary ID N 20184011940 <br /> Emy ommfsaionE ires06.09-2026 <br />