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CERTIFICATION <br /> The Applicant, $ '.1q trs: fie- (A 5g e e S L (print applicant/company name), <br /> by o c Loa'r;�At-, (print representative's name), as '(V\. p,n R r (print <br /> representative's title),does hereby certify that k u k cs `�p�-�`ens (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 3- - 'tkvt (operation name), <br /> File Number M-18 t9- 0 a <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 'R�f s•r's `1 Q fir' At, L•l.-C, Representative Name ACY-,- t,Arr,�ar� <br /> Date /p /2// / Title <br /> STATE OF Co\O.co-Lo ) <br /> ) ss. <br /> COUNTY OF \ ) <br /> The foregoing was acknowledged before me this-)l day of , 2004,by <br /> 1)�i�k, �t as f)U a.t of -! (2 9 cy ✓ • <br /> My Commission Expires: . /- ..2 4 <br /> ary Public <br /> JACKIE MALONE <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20074019912 <br /> MY COMMISSION EXPIRES MAY 21.2027 <br />