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CERTIFICATION <br /> The Applicant, _(print applicant/company name), <br /> by (print representative's name), as (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 (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?,� Representative Name <br /> Date c,u�2-_3. a Title <br /> STATE OF <br /> ) ss. <br /> COUNTY OF t (A ) <br /> The foregoing was acknowledged before me this�J day of ,20-L,by <br /> 1(,11� � as 0.��� r of <br /> +A t 6� jd_ My Commission Expires: <br /> No ary Publ' <br /> J NOTAR M MILES <br /> Y PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 20154040882 <br /> MY COMMISSION EXPIRES 1011612027 <br />