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CERTIFICATION <br /> The Applicant, Masok, Chahnir�-erI ai h, CChaMbey(a:�i& Ca"�rint applicant/company name), <br /> by Rksovk 1II'\Oim,kitrt Ith. (print representative's name), as (Y1er&be/ (print <br /> representative's title), does hereby certify that (llA (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 �Ol\1 ply- ''="k /(,hQ,1( k1904tvx CohGYe4'6 (operation name), <br /> File Number M-2010 443. <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 r7/ ,r1 Representative Name <br /> Date 3 - 24--( Title tjNef <br /> STATE OF 1riara [O ) <br /> ss. <br /> COUNTY OF (J VY1G ) <br /> The foregoing was acknowledged before me this (s day of if\cjr Jr)( , 20. -1, by <br /> S01(1 C) Cu r b u/oM11 as AriCun et?_,t- of ov►'Yl,� ( :v� <br /> .itYt4A14.4My Commission Expires: )"1(g(70 Z(o <br /> • . Pudic <br /> AMBER PRATHER <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20064032817 <br /> MY COMMISSION EXPIRES AUGUST 18,2026 <br />