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MR <br />Certification: <br />As an authorized representative ofthe applicant, I hereby certify that the operation described has met the minimum requirements ofthe <br />following terms and conditions: <br />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 ped 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 />Thu form has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-1 10,C.RS., ofthe 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.KS. <br />Signed and dated this day of <br />we, ZWS-cfmyr <br />Applicant/Operator <br />Signed: <br />Title: <br />State of <Z':_:" l d % ) <br />County tv� �— ) ss. <br />Coun of _ _ ) <br />The foregoing instrum en was acknowledged befo <br />,by 1 IC:�L1VJ rxwkv as <br />ASHLEY M. GREEN <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />NOTARY ID #20094022648 <br />My Commission Expires July 8, 2017 <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City /County Clerk <br />thiss' �+ day of V V &)I 90 Y_ <br />S n). G ", <br />Notary Public l <br />My Commission expires: 7 O6 a0) <br />SIGNATURES MUST BE IN BLUE INK <br />