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CERTIFICATION <br /> The Applicant, fkLte-////i) (print applicant/company name), <br /> by eteleg ,4 u Ai,v (print representative's name), as 19i2,e's/DeAi7 (print <br /> representative's title), does hereby certify that F rL/1 id e., 6y it,u y (structure owner) shall <br /> be compensated for any damage from the proposed mining operation totheabove/ 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 (operation name), <br /> File Number M-/9 to- 24 <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 /> ACKNOWL D "' <br /> Applic, it Representative Name L �l G W4) <br /> Date `I — 23 -2-V Title <br /> STATE OF Ce6WSO ) <br /> ) ss. <br /> COUNTY OF h// v ) <br /> (jhe oregoin was acknowledged before me thisa3 day of "/ , 20,-;74, by <br /> l✓[S GU. Houchir asr yefidek4- of ilokalji, /tic • <br /> My Commission Expires: /2/29/t DZ& <br /> Notary Public <br /> TRISHA DROSTE <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> HOTAM#Y I0 20224048949 <br /> w ::4,e4 ,"•t;s. .1 DMER29,2026 <br />