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i <br /> CERTIFICATION <br /> The Applicant, ARS Sand & Gravel Company, LLC (print applicant/company name), <br /> by Derek Garben (print representative's name), as President (print <br /> representative's title), does hereby certify that Elbert County Government (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 Elbert County Pit (operation name), <br /> File Number M- i9ss _129 <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 ARS S..A.W(�r�.,e,\ �w�^t1�.y , L 1,t,Representative Name <br /> Date 04/0V sS Title Ppmt <br /> STATE OF <br /> ) ss. <br /> COUNTY OF,-�&M,5nfr\ ) <br /> The foregoing was acknowledged before me this 6 day of , 20 a, by <br /> Dew-V_ Olnyben as of&4&Ltd& A _ �eu ,U.C.• <br /> My Commission Expires: OS-oG- o'lOQ�3 <br /> Not Public <br /> SAGE MCLEMORE <br /> NOTARY PUBLIC-STATE OF COLORADO <br /> NOTARY ID 20164017577 <br /> MY COMMISSION EXPIRES MAY 6,2028 <br />