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CERTIFICATION <br />The Applicant, Union Milling Company, LLC (print applicant/company name), <br />by, Holly Michael (pmt representative's name), as Member (pmt <br />representative's title), does hereby certify that (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 Leadville Mil! (operation name), <br />File Number W <br />This form has been approved by the Colorado Mined Land Reclamation Board pursuant to its <br />authority under the Colorado Land Reclamation Actfor the Extraction of Construction Materials and <br />the Colorado Mined Land Reclamation Act for Yard Rock, Metal, and Designated Mining Operations. <br />Any alteration or modiJ%ation to this form shall result to voiding this form. <br />NOTARY FOR PERMIT APPLICANT <br />ACKNOWLEGED BY: <br />Applicant u n i o n rY1 I I ;, g �o► r2a n LI t'epresentative Name <br />Date 1.1 _ - r <br />STATE OF e Cl L-- ) <br />COUNTY OFF <br />i{egoing was acknowledged before me this day of 20 by <br />1 t :s c a .Q_ 1 as vvtt C� <br />.a , ^�� of —LA n� rh;ll•.tw 0DMj00.,%y � <br />My Commission Expires: _ f <br />R •'•latpc•Piib es <br />