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-7- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements ofthe <br />following terms and conditions: <br />1. All necessary approvals from local government have been applied for (Section 34- 32.5- 110(1)(a)(VIII). <br />2. To the best of my knowledge, all significant, valuable and permanent man -made structure(s) in existence at the time this <br />application is filed, and located within 200 feet of the proposed affected area have been identified in this application <br />(Section 34- 32.5- 115(4)(e), C.R.S.). (NOTE: For 110 operations, the affected area includes all lands delineated by the permit <br />boundary.) <br />3. No mining operation will be located on lands where such operations are prohibited by law (Section 34- 32.5- 115(4)(f), <br />C.R.S.). <br />4. As the applicant/operator, I do not have any mining/exploration operations in the State of Colorado currently in violation of <br />the provisions of the Colorado Land Reclamation Act for the Extraction of Construction Materials (Section 34- 32.5 -120, C.R.S.). <br />5. I understand that statements in the application are being made under penalty of perjury and that false statements made herein <br />are punishable as a Class 1 misdemeanor pursuant to Section 18 -8 -503, C.R.S. 1984. <br />Thu form has been approved by the Mined Land Reclamation Board pursuant to section 34- 32.5- 110,C.R.S., of the Colorado Land <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of this form shall result in voiding any <br />permit issued on the altered or modified form and subject the operator to cease and desist orders and civil penalties for operating <br />without a permit pursuant to section 34- 32.5 -123, C.R.S. <br />Signed and dated this �� r4 day of � -, S � I :� z, 1/ 3 <br />0z' <br />Applicant/Operator <br />Signed: <br />v <br />Title: Land Use Administrator <br />State of >� O f ) <br />ss. <br />County of L 1 -� C.c ;� ✓\ ) <br />The foregoing instrument was acknowledged before m this <br />,by Lh n 1�e W ; as l.11J2 <br />MINDY SCHIFFERNS <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />NOTARY ID # 20134026866 <br />PAY COMMISSION EXPIRES APRIL 30, 2017 <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City /County Clerk <br />day of c U 13 <br />Clsri(Lt i'rk f <br />Notary Public n <br />My Commission expires: <br />SIGNATURES MUST BE IN BLUE INK <br />