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1 <br /> CERTIFICATION <br /> The Applicant, QB Energy Operating, LLC (print applicant/company name), <br /> by Ed Seymour (print representative's name), as Surface Land Manager (print <br /> representative's title), does hereby certify that N/A (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 Circle Dot Quarry (operation name), <br /> File Number M-2007-067. <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 Q tAr.,,,i,,,TI(CRepresentative Name � Uyt,14o41— <br /> Date /0/ 1 ` 2 ZGt Title &N( Ca as4. Mal 'r- <br /> STATE OF COO -0 ) <br /> ss. <br /> COUNTY OF ,---C4re)119k ) <br /> VdayThe ore ing was acknowledged before me this ( <br /> of 6 C+ " , 20 2`f by <br /> ryl 011k- a*3 i.G LL 4( of 'j£ l\R fLjy ()fermi Lt.(, . <br /> . &P J My Commission Expires: b 1 1 C 2., 6 M <br /> Nota ubl <br /> MAKAYLA M.GRANT <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20174035951 <br /> MY COMMISSION EXPIRES 0811/2026 <br />