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The Applicant, <br />,tcx hj., id <br />CERTIFICATION <br />Stone Canyon Quarry, LLC <br />S <br />(print applicant/company name), <br />by Brenda Buster (print representative's name), as Manager <br />representative's title), does hereby certify that Brenda Buster (house) <br />(print <br />(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 Stone Canyon Quarry, LLC <br />File Number M2012 -018. <br />(operation name), <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 />ACKNOWLEGED BY: <br />Date %/ <br />STATE OF C016W <br />) ss. <br />COUNTY OF `hr)l,r.lo( ew) <br />Representative Name <br />Title %%%5:r!1 Q ! <br />The foregoing was acknowledged before me this 5-f' day of 5-e Vi1mb -e ✓ , 20 2 by <br />F'r �� St-�✓ ashy -��- e�-e -� of JL�Y1� �cc v�c�Cwl C�(,crL��y zLc <br />C-� -1 1 ZZ41 <br />blic <br />TAYLER N WRIGHT <br />Notary Public <br />State of Colorado <br />My Commission Expires: 2 ' 2" 20 <br />