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CERTIFICATION <br /> The Applicant, Rt Vt S 6L P gqc t g L t t.5, L.L.L (print applicant/company name), <br /> by (print rreep✓reseenntative's name),as (print <br /> representative's title),does hereby certify that 13(.v\JI frt. n P\p, , t. (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 iNkt,oi ,n„�. p; (operation name), <br /> File Number M- - <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 C./cc-5 0435 cc,Sre.7 Lt-1—Representative Name <br /> Date e//J�f , Title <br /> STATE OFCt)\�'c ) <br /> )ss. <br /> COUNTY OF? ) <br /> The foregoing was acknowledged before me this IS day of 1 ,20 ,by <br /> 1/4\43rV.--O Q utrc-N as e c- of k o r �t l f-,izsC'?"nt 5 <br /> ) \ dy1.&..J My Commission Expires: 9 )" 02 0,Z7 <br /> No Public <br /> JACKIE MALONE <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20074019912 <br /> MY COMMISSION EXPIRES MAY 21,2027 <br />