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RECEIVED <br /> JUL 0 2 2024 <br /> Colorado Division of Reclamation, <br /> CERTIFICATION Mining and Safety <br /> The Applicant, _13 A 0 ©/-C'i4 f 19LA CR"K-JyridtNe, C' (print applicant/company name), <br /> by 144 e,a,fi-r S. 4R4fl4-_*rint representative's name), as 04j v (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 6 A D •y I'(j „/„w S (operation name), <br /> File Number M- - <br /> 1" <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 L&D & i/s m/GRi PP LI Representative Name WAi f Q l�S. ��144 <br /> e4,=� -j N9 N4 Ue— <br /> Date LZ!4 Title C;WN�,--- <br /> STATE OF &a!®RApa ) <br /> )SS. <br /> COUNTY OFF 1 i„o�Q- ) <br /> The foregoing was acknowledged before me this If day of ,20x,by <br /> 14 444t OT"s qk'.• AI Ai Y as 0.,1tVe it— of A,-u Bo VA OF 411?I JO .6 C� <br /> r4ffJl y C0 <br /> 0�.1 <br /> nn1.1-c <br /> I "MIA My Commission Expires: <br /> otary b <br /> ll c <br /> Taylor N S :rr Taylor N Safes <br /> NOTARY PUBLIC NOTARY PUBLIC <br /> S: E OF COLORADO STATE OF COI WW <br /> NOD <Y i,# NOTARY ID#2022400 = <br /> Allf COMMISSION EXPIRES 10/11/= MV COMMISSION EXPIRES 10111/20Z6 <br />