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CERTIFICATION <br />k .3260-1- <br />The Applicant, 14/4 /.{ cAalt/ A (print applicant/company name), <br />by PAT fie brde (print representative's name), as .0 Um/ (print <br />representative's title), does hereby certify thatyAmpAlVigg gy EA ea; 'Ks, 11, (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 Aia0A,//3)7- (operation name), <br />File Number M - 4,43 <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, Meta4 and Designated Mining Operation& <br />Any alteration or modification to this form shall result in voiding this form. <br />NOTARY FOR PERMIT APPLICANT <br />a/ <br />ACKNOWLEGED BY: <br />Applicant IA-v;(11 airy:tow( 6... Representative Nand( r <br />Date 's 1 <br />STATE OF I d NO( 11 <br />) ss. <br />COUNTY OF <br />Title <br />The foregoing was acknowledged before me this day of 114:Uf 201,7:) by <br />as r cyve of • , r( atei (e71 <br />---) <br />t:LX My Commission Expires: C 1 ( -dC <br />