2012-08-08_PERMIT FILE - M2009056

• Permit No: M2009056
• IBM Index Class Name: PERMIT FILE
• Doc Date: 8/8/2012
• Doc Name: RETURNED MAIL: PRELIMINARY ADEQUACY REVIEW
• From: DRMS
• To: DESTINY MINING
• Email Name: MAC
• Media Type: D
• Archive: No

The Applicant,
by
representative's title), does hereby certify that
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
(print representative's name), as
NOTARY FOR PERMIT APPLICANT
The foregoing was acknowledged before me this day of
as of
Notary Public
My Commission Expires:
(print applicant /company name),
(print
(structure owner) shall
, 20 , by