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CERTIFICATION <br /> The A plicant, P B & S Sand and Gravel LLC (print applicant/company name), <br /> by -Kali(J/LEirc.t % (print representative's name), as Q t K (print <br /> representative's title), does hereby certify that San Isabel Electric Association(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 Ghost River Gravel 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—atkilik, � Representative Name "M'r--1 <br /> Date /XV,/ Title -- <br /> STATE OF Ooto r _) <br /> ss. <br /> COUNTY Of ) <br /> T oregoing was acknowledged b fore me this .o day of , 20.x(, by <br /> - EC 5J as_ � — — of a • 4144 Ae (A-4. <br /> My Commission Expires: / / /� <br /> ary 'ub ►c ttt <br /> JODI 0 SCHREIBER <br /> NOTARY PUE3UC <br /> STATE OF COLORADO <br /> NOTARY ID 20064001792 <br /> MY COMMISSION EXPIRES OCTOBER 6,2026 <br />