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The Applicant, City of Greeley (print applicant/company name), <br />b Jon Monson (print representative's name), as Director of Water and Sewer ( <br />representative's title), does hereby certify that Martin Marietta Materials (structure owner) shall <br />be compensated for any damage from the proposed mining operation to the above listed structures) <br />located on or within 200 feet of the proposed affected area described within Exhibit A, of the Reclamation <br />Permit Application for Treiber Lakes (operation name), <br />File Number M-2011-049 <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 />ACKNOWLEGED BY: <br />Applicant City of Greeley Representative Name \ <br />Date September 20, 2012 Title Jon Monson, Di for of Water and Sewer <br />STATE OF Colorado ) <br />) ss. <br />COUNTY OF Weld <br />The foregoing was acknowledged before me this( 9 d of <br />30 Ys M Oin SO r\ as Dl h Le..�k r• of <-Llti• <br />CERTIFICATION <br />NOTARY FOR PERMIT APPLICANT <br />201 Z, by <br />My Commission Expires: I - 30 <br />