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J <br />Certification: <br />E LC L � W E <br />7 - FE0 10 - 2014 <br />4. <br />FIELD <br />As an authorized representative ofthe applicant, l hereby certify that the operation desc bed has <br />following terms and conditions: <br />All necessary approvals from local government have been applied for (Section 34- 32.5- 110(1)(a)(Vlll). <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 applicantloperator, I do not have any mining/exploration operations in the State of Colorado currently in violation of <br />the provisions ofthe Colorado Land Reclamation Act for the Extraction ofConstruction Materials (Section 34- 32.5 -120, C.R.S.). <br />5. 1 understand that statements in the application are being made under penalty of perj ury 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 />This form has been approved by the Mined Land Recianodon BoardtpnrxwWto section 34 -32. S -110,0 RS., ofthe Colorado Land <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of this form s*gfl result in voiding any <br />permit issued on the altered or mod fled 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. i <br />Signed and dated this day of ��h , 6/,-/ <br />Applicant(Operator <br />Signed: L � "'..- <br />Title: ati1 ! ;� ,.T <br />State of <br />�.( ) ss. <br />County of ; 'd <br />If Corporation Attest (Se} <br />Signed: <br />j d <br />Corporatd retary Equivalent. <br />/ Town/City/County Clerk <br />The foregoing instrument was <br />a�ck� now mL�7 l/h:is - 4 !t•Co i -, day of <br />e1) <br />'X, VC J' as _ J o- f C�) ' : �G d LG'Gti. . <br />lNotary Public <br />y; <br />tii 7�E <br />it-IF -, h-.j L'; N M. ` <br />ntu4k—g.. Jjl�r- kci- Z14 114 2L4) <br />'c� L ��. <br />My Commission expires: ; -� �� � � <br />SIGNATURES UST 1 <br />Inn <br />RECEIVED <br />FEB - 5 2014 <br />RIO GRANDE CNTY CLERK <br />