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CERTIFICATION <br /> ThApplicant, �� .Z '�l '� , <br /> l (print applicant/company name), by <br /> c <br /> b ' c c c\ e -c4V-1 (print representatives rime, as C.)i%41e"i"ss (print <br /> representative's title), does hereby certify thatc'rif F'' K`� ` R�%c`�� _(structure owner) <br /> t,4.s r. a^S �, � <br /> shall be compensated for any damage from the proposed mining operation to the above <br /> listed structure(s) located on or within 200 feet of the proposed affected area described <br /> within Exhibit A, of the Reclamation Permit Application for 0u.k ( f f.EGA y c Ct -t I?T <br /> (operation name), File Number M- I�00114 <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 /> ACKNOWLWGED BY:. <br /> /, ,r� <br /> Applicant r%Ct _Lip:,//6 vfl L L C._....- Representative Name N C),C1 C�Cc_,� � C <br /> ,j r <br /> Date z ���'�� Title /4/1 -, 0'1 <br /> STATE OF ( (' <br /> _.(i 0 r'`,^_cAD ) <br /> )ss. <br /> COUNTY OF L (---- ) <br /> The foregoing was acknowledged before me this 5 day of LA � Sr 20 - �, by <br /> / ,. <br /> ' 4.4,11, <br /> , My Commission Expires: c:712//// c27 <br /> N Public <br /> Suzanne E Crider Walden <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY IDS 19984012442 <br /> MY COMMISSION EXPIRES 4/11/2028 <br />