2012-09-24_PERMIT FILE - M2011049

• Permit No: M2011049
• IBM Index Class Name: PERMIT FILE
• Doc Date: 9/24/2012
• Doc Name: Information for City of Greeley, Structure Agreements.
• From: Blue Earth
• To: DRMS
• Email Name: ECS
• Media Type: D
• Archive: No

The Applicant, City of Greeley
2011.. 049
ary Public
CERTIFICATION
b Jon Monson (print representative's name), as Director of Water and Sewer ( pr i nt
representative's title), does hereby certify that Century Link (structure owner) shall
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 Treiber Lake (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.
NOTARY FOR PERMIT APPLICANT
ACKNOWLEGED BY:
Applicant City of Greeley Representative Name
Date September 20, 2012 Title Jon Monson, Dire for of Water and Sewer
STATE OF Colorado )
Weld ) ss.
COUNTY OF )
he foregoing was acknowledged before me this °ay of
as of
la x a.rLa
My Commission Expires: I — 30 —IS
(print applicant/company name),
20R .by