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The Applicant, Cooley & Sons Excavating, Inc. <br />(print applicant /company name), <br />b James Cooley (print representative's name), as President (print <br />representative's title), does hereby certify that Farmer's Union Canal (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 Screening /Crushing Agg. @ Pepper Recharge Pit (operation name), <br />File Number M- 2011 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 ,Ripresentative Name <br />Date /— <br />STATE OF 1. i- ) <br />/ 1 ) ss. <br />COUNTY OF1 .itii)(hL(L, ) <br />T e foregoing was acknowledged be re me this .� / day of <br />� r <br />AA r 4 (r"rl, 1 a -,1 t,9,t {t C,, - of <br />Notary P <br />blic <br />f <br />NOTARY FOR PERMIT APPLICANT <br />CERTIFICATION <br />Title President <br />My Commission Expires: <br />y <br />20 . , by /} <br />.3 <br />llu_1 �L L <br />