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The Applicant, S/ (2 il CJ ey'C r, /.(print applicant/company name), <br />by f re/K Tom. S` &- (print representative's name), as iI - (print <br />representative's title), does hereby certify that..,r..g 0 , 7 4 , �f�,, 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 f )fie / C, r <br />21 <br />File Number M-,26/.2 k / 2 - Q/ <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: ��sentative Na <br />** <br />t �, I e 3eme <br />Applicant :Sky { /t�/. ;� (�c.r��' / p <br />Date / � / Title �. <br />/7 <br />STATE OF ( .1.) <br />Ci ' <br />ublic <br />DEBORAH S. KENT <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />CERTIFICATION <br />( s! l (: r - r <br />NOTARY FOR PERMIT APPLICANT <br />4 ( (operation name), <br />)ss4 <br />COUNTY OF cfi,_.t.,6( ; 4-- <br />The foregoing was acknowledged before me this /a day of A=e rvi 17-ev , 20j, by <br />` 3 e r - )rCct ' r as ►`n eje of Car atGUr( - -( <br />- -I3 �3 <br />My Commission Expires: <br />to o <br />