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CERTIFICATION <br /> The Applicant, Bestway Concrete Company . (print applicant/company name), <br /> by Mark Johnson (print representative's name), as VP Aggregates __(print <br /> l .2 <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 Lupton Meadows Gravel Mine (operation name), <br /> File Number M-2016- 076 . <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 E.ztraction 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 forjn shall result in Voiding this form. <br /> NOTARY FOR PERMIT APPLICANT <br /> ACKNOWLEGED BY: <br /> Applicant`Bestway Concrete Comte r�_�__ Representative Name Mark Johnson\ <br /> Date_ Novemberl , 2016 Title VP Aggregates <br /> STATE OF (n-.owl,, <br /> ) ss. <br /> COUNTY OF ujtU� ) <br /> The fore=oing was acknowledged before me this day of_04.ICVA ,L 201& by <br /> as W k —of <br /> 1 <br /> kMy Commission Expires: 11 t 2 11 <br /> Notary Public I' <br /> ANDY Fi:? ►i��:i�:; <br /> NOTARY PUt30C <br /> STATE OF COLORADu <br /> My Commissin w Fxnir(3R on� <br />