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ACKNOWLEGED BY: <br />, <br />Applicant iUf (X/ atY( (21(2t. <br />Date - <br />STATE OF((...4('I Ct(l C <br />) ss. <br />COUNTY OFI ) <br />gERTIFI CATION <br />The Applicant, ///4A e ' .5 .4 4 (print applicant/company name), <br />by PAT tole btu (print representative's name), as 0 1.4//V eti) (print <br />representative's title), does hereby certify thatyAmprilhil e/ EA eer 4.4.,914 (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 ye /7)r M (operation name), <br />File Number M- <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 />The foregoing was acknowledged before me thi day of <br />7 l as k. _k..br I ,t," of <br />y Commission Expires: - f.K I 5 <br />Representative N e i <br />Title V: b <br />iLf <br />