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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 NSA (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 West Fork Gravel Pit (operation name), <br /> File Number M-2005-069. <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 -a, &yy„p,,r-- <br /> Date JO/ l I QO2bL( Title 3uX„..., LA .,.f'- <br /> STATE OFG_WA-0 ) <br /> ci ) ss. <br /> COUNTY OF 1 <br /> The foregoing was acknowledged bef9re me this I day of 20- by <br /> `z k i as SZA vlldna 6f r Ail L( <br /> PR-- H---- -� My Commission Expires: d , ) t 2 U Z F <br /> Notary Pub lc <br /> MAKAYLA M.GRANT <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY IO 20174035954 <br /> MY COMMISSION EXPIRES 08/11/2026 <br />