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0 <br />CERTIFICATION <br />The Applicant, Stone Canyon Quarry, LLC (print applicant/company name), <br />by Brenda Buster (print representative's name), as Manager (print <br />representative's title), does hereby certify that <br />Poudre Valley REA <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 (operation name), <br />File Number M-2012 -018. <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 />Applicant riQZepresentative Name rz° a <br />Date / Title CE 0c— <br />STATE OF <br />) ss. <br />COUNTY OF ) <br />T�e foregoing was acknowledged before me this 5-" day of 13f pt-e., O /Z , by <br />as WqxLa-oj,� of '5&yu C &6C <br />C My Commission Expires: 2 'Z' 2b1 q <br />N tary blic <br />TAYLER N WRIGHT <br />Notary Public <br />State of Colorado <br />