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CERTIFICATION <br /> The Applicant, C RCS Zn-L (print applicant/company name), <br /> by 01.:CL0.c f Ca/I ew...b4print representative's name), as President (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 Yampa Valley Gravel Pit (operation name), <br /> File Number M-2011_0170..j ae„..4 <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: Ue,, j <br /> &uwh(tyi <br /> Applicant -' CCO) 0 L#1' Representative Name ''(n/ t`C,6 C �1 <br /> Date /0Y/204 Title AtA,Lotsal„,_ 4_ 00 <br /> STATE OF oderiadt)- ) <br /> � ss. <br /> _ <br /> COUNTY OF f'SD ) <br /> The foregoing was ac owledged before me thisc ' day of LA 4 , 20 by <br /> �dc - s PreS i 4- of I C/f2ft i d i - . <br /> My Commission Expires: 0 I1 g3) d,0 <br /> Notary Public <br /> CO7ZENS <br /> WARY PUBLIC <br /> 3T4A►ta OF C_QLORADO <br /> WARY ID 244003079 <br /> lid t biliiit iON EXPIRES moon <br />