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CERTIFICATION <br /> The Applicant, ROltI45 �j� uG CAn&—Tr uck i r c (print applicant/company name), <br /> by Richard kQ1Lt QO1tIt(print representative's name), as Owiv/r (print <br /> representative's title), does hereby certify that frItlion Co6T (Anti (►/ s' ` tructure 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 ' j .t 4. G,c, QA (operation name), <br /> File Number M-ZOO-p[ <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 QOJIif15 CO d.jc. atISTIliCkinRepresentative Name -‘ td Val 14 20I`ins <br /> Date ia -!D-as Title (1wnQ, ' _ <br /> STATE OF LA11n ) <br /> ) ss. <br /> COUNTY OF I V Q-1. ) <br /> The foregoing was acknowledged before me this {60 day of At 20.25;'_b'y -T VOit'in5 as Ov3(tier of Ljr�s CLjtE ( o64 ` lCki <br /> Nt <br /> My Commission Expires: 0e4o - 1 11003 1 <br /> Notary Public <br /> ' CAROL ANN GRAY <br /> I i•'�' a Notary Public.stag.o/Utah <br /> �*733637 <br /> r Aclobar 11.� <br />