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CERTIFICATION <br /> The Applicant, 21 r+- tL�- s LLCr (print applicant/company name), <br /> by 5�. e— C _(print representative's name), as C Lorlp-r (print <br /> representative's title), does hereby certify that Fmm (structure owner) shall <br /> be compensated for any damage from the proposed mining operation tot e 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 od I ahassee Pi (operation name), <br /> File Number M- I qqq-b03. <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 IC,— Representative Name AV C C�OIdt-6-1 <br /> Date �� ��c20d V Title l•3 A�� <br /> STATE OF Co <br /> ss. <br /> COUNTY OF � o-,-n v) <br /> The foregoing was acknowledged before me this day of J L.-yll- - , 20 , by <br /> C)Df as 7 i'1 of I i(4 <br /> I WL 0-a,4-Uq - My Commission Expires:'TN <br /> ry Public <br /> LINDA CASEY <br /> NOTARY PUBLIC-STATE OF COLORADO <br /> NOTARY ID 20184002983 <br /> MY COMMISSION EXPIRES J04 18,2026 <br />