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CERTIFICATION <br /> The Applicant, 'D k 4 2u , - L_ (print applicant/company name), <br /> by ShCU &Ug_,r (print representative's name), as (pU3 e (" (print <br /> representative's title), does hereby certify that 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 7o__j jAhassee_ ei-f (operation name), <br /> File Number M-/M.- 0S . <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 Representative Name <br /> Date_X /C(' L> �l Title ®fit AJL�_ <br /> STATE OF <br /> ss. <br /> COUNTY OF V-e y,\0 <br /> The foregoi was acknowledged before me this q day of J u Yl — , 20--�A by <br /> ��hcx� hp e-, as Doti Lr� C)-p_ t'' of ; tom; s PLC. <br /> My Commission Expires: iletyULgal <br /> Public <br /> LINDA CASEY <br /> NOTARY PUBLIC-STATE OF COLORADO <br /> NOTARY ID 20184002983 <br /> MY COMMISSION EXPIRES JAN 18,2026 <br />