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P ` <br /> CERTIFICATION <br /> The Applicant, >J . County Road and Qt,.4# (print applicant/company name), <br /> by`;•r•/1(IA-e e_ (print representative's name), as Rocd and errcjv si ferusor(print <br /> representative's title), does hereby certify that Tot, f/Cw. ..." (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/Yeivi.oi, p;4- (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 Yuma- Coo h+7 Ron aA.1-131' Representative Name--', ti <br /> Date C.3//9/10,1 r TitlePoa4 anb ham.11/2/.. C(-pd.rife <br /> AO COCvi' <br /> STATE OFro re ) <br /> ) ss. <br /> COUNTY OF ) <br /> The foregoing was acknowledged before me this I t day of Nla rcln , 20 2S-by <br /> 1 Ftrd�r.Sc_r1 <br /> as 5.j.ix,r v-i s b r of w� L cr..t .► c� <br /> My Commission Expires: (D/ t o/2024P <br /> ota blie <br /> tHRYSTA.A oONo oRAoo <br /> NOTARY PUBLIC' 9 11012026 <br /> Note�Y�p#201i�539618 <br /> My Commi5510n p <br />