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CERTIFICATION <br /> The Applicant, QB Energy Operating, LLC (print applicant/company name), <br /> byEd Seymour (print representative's name), asSurface 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 Colony Oil Shale Project (operation name), <br /> File Number W 980-047. <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 QB Energy Operating, LLC Representative Name ---� <br /> Date November 14, 2024 Title Land Manager <br /> STATE OF Colorado ) <br /> ss. <br /> COUNTY OF Denver ) <br /> The foregoing was acknowledged before me this day of 1JgVewbe , 20A, by <br /> 12fouf as -d Wa7a�of , <br /> My Commission Expires: 1-2 7 7-09-5, <br /> Notary Publ' <br /> JEFF KROSKY <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20124081019 <br /> MY COMMISSION EXPIRES FEBRUARY 27,2025 <br />