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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,f)2 Title County Administrator <br /> STATE OF Colorado ) <br /> ss. <br /> COUNTY OF Cheyenne ) <br /> T or oin wI�acknowledged before methis��day of r ,20 ,by <br /> o Ky�e� as L_c[nG(Q �n er of <br /> 41m, � ,L4 riL, My Commission Expires: 2�— <br /> Notary blic <br /> patty J Hevner <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20134012414 <br /> MY COMMISSION EXPIRES NOVEMBER 21,2025 <br />