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CERTIFICATION <br /> The Applicant, (,J6sT ti'r e Pk4.W/1. a I.-5 L{print applicant/company name), <br /> by S e-a v M'--' (print representative's name),as ✓P o F d ez t:a r'o --1S (print <br /> representative's title),does hereby certify that `-`t 61-'sI e►'•"`‘`t (structure owner)shall <br /> be compensated for any damage from the proposed mining operation to the above listed structures) <br /> located on or within 200 feet of the proposed affected area described within Exhibit A,of the Reclamation <br /> Permit Application for L o s Q.-r (operation name), <br /> File Number M-(`s bt 068 <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 /t)e->rd s L-0P4 Iota--c-.:A '4 Representative Name 51-14--", .S,C-a^I M `-`v <br /> Date 1 /zt, 2 1r Title ki‘c.z.. enst 1/4n o Fr o Po <br /> STATE OF Colo(am.p0 ) <br /> )ss. <br /> COUNTY OF Go,. ►e� ) <br /> The foregoing was acknowledged before me this ZG day of ..N‘)1y ,2014,by <br /> rne,lto as V,(.4/.. re‘)d44 of optsf ' wes N Slope. r`k*e- <br /> !N' My Commission Expires: Gi/y/ZoI.s"— <br /> Notary Public <br /> TIMOTHY OLK <br /> Notary Public <br /> State of Colorado <br /> Notary ID#20164038408 <br /> My Commission Ex.ires 01-27-2025 <br />