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CERTIFICATION <br /> The Applicant, �c ,E',r?�"j ram' z= il'C �G "! L 4C (print applicant/company name), <br /> by sal r�¢,� �`,�,o,Pi,a (print representative's name), as (print <br /> representative's title), does hereby certify that ,V��mid -- l'er, (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 - ,��,y-� �rf-. (operation name), <br /> File Number M- et> . <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 /> ACKNOWLEDGED BY: <br /> Applicant JC :',�'�'S i� l� r• G,o7` s Representative Name <br /> Date oZ �� Title <br /> STATE OF 1p,r ) <br /> ss. <br /> COUNTY OF F ) <br /> V <br /> The foregoing was acknowledged before me this day of�.a-' /'Yi ,�° , <br /> as f <br /> My Commission Expires: <br /> btarvy Public <br /> CASSW A HERNANDEZ <br /> NOTARY PUBLIC <br /> State of Colorado <br /> Notary ID#20244007610 <br /> My Commission Expires 02/22/2028 <br />