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The Applicant, Cooley & Sons Excavating, Inc. <br />b James Cooley (print representative's name), as President <br />representative's title), does hereby certify that Farmer's Union Canal <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 Screening /Crushing Agg. @ Pepper Recharge Pit (operation name), <br />File Number M- 2 034 <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 />ACKNOWLEGED BY: <br />Applicant Cooley & Sons Excavating ,Rilvresentative Name <br />Date /— <br />STATE OF (AJ ) <br />0E4/y6(2/leo ) ss. <br />COUNTY OF ) <br />T e foregoing w ssaacknowledged be re me this ,2 day of <br />3 mrn Co�r ( as L4IlALd n. ;L of <br />CERTIFICATION <br />NOTARY FOR PERMIT APPLICANT <br />Title <br />President <br />- (141,atu , 20 ;� a ; by <br />)o-7=4 <br />My Commission Expires: 311 /a0 �S <br />(print applicant /company name), <br />(print <br />(structure owner) shall <br />