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CERTIFICATION <br /> The Applicant, Asphalt C_--onstructors, Inc -.(print applicant/company name), <br /> br Todd Stockebrand (print representative's name), as__ &exj (print <br /> Mountain Meadows Realty Corporation shall <br /> representative's title), does hereby certify that _------ _._ .._ (structure owner) <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 Smith Pit (operation name). <br /> File Number NI-f9Tl -053 <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 /> • <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> Applicant_2' -- (l/ i 3 44 d Ab <br /> Representative Name To t143t ►rt�.►.�. <br /> AMVV'te3t4 es, tat • <br /> Date 6\n\dbt Title Ate5ilittlAk <br /> STATE OF Ntt _) <br /> ) ss. <br /> COUNTY OF_ p,--- <br /> The foregoing was acknowledged before me this_I,t _day of � ,�20�5, by <br /> e gt Ao�auyi as__ Ase of n elN6141 'seittc <br /> .410/11 — l My Commission Expires: /01(p Joao <br /> o . 'ublic <br /> MY CO lu' I <br />