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S's <br /> CERTIFICATION <br /> A' <br /> tc <br /> The Applicant. (print applicant/company name), <br /> b> _-._._._. (print representative's name), as MR. <br /> ___. _ _ _(print <br /> representative's title),does hereby certify that (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 Ajax 1 (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 /j pm 5 Representative Name 4 e ` 3 S <br /> Date 3 ill h 5 Title QQ <br /> STATE OF 1 ex- } <br /> ) ss. <br /> COUNTY OF Hap ) <br /> The f regoing was acknowledged before me this /�l iklay of I'�106 k , 20<)5, by <br /> -1 -( e t as nda7 of l erects <br /> -atCts___ My Commission Expires: 0-J 3- ,;g <br /> Notary ublic ``.`; E S` 7, <br /> %A.r.''OTA)jy.r <br /> ,,lIsIIIItt%‘` <br />