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ACKNOWLEGED BY: <br />Applicant (JS, d <br />Date He / <br />STATE OF CAA CY a 4. p <br />COUNTY OF' MA.) <br />P.v °S <br />) s s. <br />CERTIFICATION <br />The Applicant, RIVERSIDE AGGREGATES , LLC (print applicant/company name), <br />b RUDY TORRES (print representative's name), as Member (print <br />representative's title), does hereby certify that N/A (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 Limited Liability Company (operation name), <br />File Number M- <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 />K ie t ,¢ w9`, Representative Name <br />(l Title 11 01 (O, <br />The foregoing was acknowledged before me this IL day of Jan UJ Y'U , 2013, by <br />- F. 1 - M Y r-e S as P,n P r of v S; d e I�(,+ r "t1 i LIZ <br />VO N1 �1(,(,{, My Commission Expires: v2 — (G' — 1 (' <br />