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CERTIFICATION <br /> The Applicant, Cheyenne County (print applicant/company name), <br /> by Marcy Brossman (print representative's name), as County Administrator (print <br /> representative's title), does hereby certify that Clifford R. Roberts (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 Roberts 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 /> ACKNOWLEGED BY: <br /> Applicant Cheyenne County Representative Name Marcy 4ossman <br /> Date y'(y'a3 Title County Administrator <br /> STATE OF Colorado ) <br /> ) ss. <br /> COUNTY OF Cheyenne ) <br /> T or oin w//a��ss acknowledged before me thisA4day of � , 2O�23, by <br /> as L 4 ncFown er of 4 ov,--Oae-r)�V <br /> My Commission Expires: <br /> 4)4 <br /> Notary blic .rF. <br /> patty J Hevner <br /> FNOTARY <br /> OTARY pUBLIC <br /> TE OF COLORADO <br /> 1D 20134072434 <br /> N EXPIRES_NOVEMBER 21,2025 <br />