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CERTIFICATION <br /> The Applicant, P B & S Sand and Gravel LLC (print applicant/company name), <br /> by Pittyj(k Skit (print representative's name), as (print <br /> representative's title), does hereby certify that Huerfano County (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 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 t4 Representative Name �L .-► <br /> Date---_M aja}-- Title IQ k1ll z <br /> STATE OF PA1,41,44/4:1) <br /> ) ss. <br /> COUNTY OF ALLE,b ) <br /> Th ' regoing was acknowledged before me this day of . 20 by <br /> as At0s44. of --'-J jiiii4-4441.oiat Y,I Liz. <br /> OAa‘ _ _ My Commission Expires: /0 0L9- ,,, <br /> 1os� u l ic; <br /> JODI 0 SCHREIBER <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20064001792 <br /> MY COMMISSION EXPIRES OCTOBER 6,2026 <br />