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CERTIFICATION <br />The Applicant, Union Milling Company, LLC (print applicant/company name), <br />by Holly Michael (print representative's name), as Member (print <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 Mill (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 forms <br />NOTARY FOR PERNUT APPLICANT <br />ACKNOWLEGED BY: <br />nn <br />Applicant L,�n i on M 1 I I a Cp- U-C.Representative Name <br />Date /-2- 17 - / a- Title M 2,,n b Q r' <br />STATE OF C p L a , ) <br />r--- ) ss. <br />COUNTY OF 0e F F, ) <br />T e foregoing was acknowledged before me this 17 day of ! � . , 20/A by <br />YY1 r C- ha e l as r&Z m !� of C <br />i u n Vh ; 1I i,i �'o,x,Pany <br />Z,y,•' ,�• •� Commission Expires: <br />' <br />R XV .. <br />