2012-02-17_PERMIT FILE - M2012004 ‎(2)‎

• Permit No: M2012004
• IBM Index Class Name: PERMIT FILE
• Doc Date: 2/17/2012
• Doc Name: New 110c Application
• From: Superior Oilfield Services Co., LTD
• To: DRMS
• Media Type: D
• Archive: No

The Applicant, (print applicant/company name),
by (print representative's name), as (print
representative's title), does hereby certify that (structure owner) shall
be compensated for any damage from the proposed mining operation to the above listed structure(s)
located on or within 200 feet of the proposed affected area described within Exhibit A, of the Reclamation
Permit Application for (operation name),
File Number M-
This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its
authority under the Colorado Land Reclamation Act for the Extraction of Construction Materials and
the Colorado Mined Land Reclamation Act for Hard Rock, Metal, and Designated Mining Operations.
Any alteration or modification to this form shall result in voiding this form.
ACKNOWLEGED BY:
Applicant Representative Name
Date Title
STATE OF )
) ss.
COUNTY OF )
CERTIFICATION
NOTARY FOR PERMIT APPLICANT
The foregoing was acknowledged before me this day of , 20, by
as of
My Commission Expires:
Notary Public