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CERTIFICATION <br />The Applicant, 'jam Pn h (,ii & x 5 (print applicant/company name), <br />by p zr o. � 0 2 (print representative's name), as Cd c r -ti -(0 A (print <br />representative's title), does hereby certify that 1�011 1 Gt c. y � x A o,- ti fy a v, structure owner) shall not <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 C D rn 4) , r\ r-, -t i C v'X e L Ci C 0-2 (operation name), <br />File Number M- <br />This form bas been approved by the Colorado Mined Laud 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 Reclamcaon Act for Hard Rock, Ma&A, and Designated Mining Operations. <br />Any alteration or modification to this form shall result in voiding this form. <br />NOTARY FOR PERMIT APPLICANT <br />ACKNOWLEGED BY-. G <br />Applicant &,-i c l' /1 L) r�' s Representative Name � c (� � ✓ tx --s <br />Date 11 / -2 o.z 3 Title Lao, c I o ,L <br />STATE OF C"^,! v c �i t� ) <br />) ss. <br />COUNTY OF C <br />Tbe foregoin was acknowledged before me this day of t,tic, , 20L, by <br />r <br />as of l Oli�cicc., rxJtov•ct4 t 0r,- ". <br />1Ar c " E>1M lane 13, 2013 <br />3110 NAM NrA6 AvOw <br />AU71 al) % Ci ,)— My Connnission Expires: Co@ab *6W Co Nl07 <br />Y Public <br />