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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 of the <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 pennit <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 />This form has been approved by the Mined Land Reclamation Boardpursuant 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 modifted 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 doted this �� day of r E6 (z, LA e w <br />State of (2D l02 w�O ) <br />) ss. <br />County of LOTS An I yk"'As ) <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Toxvri/City/County Clerk <br />The foregoing instrument was acknowledged before /me�this � I � - day of �LL-Qn,j a6 I <br />'� `f <br />by Ci�42y �. i�l 1 as lei'la!►'r-YICLe) of Aorlyd er rtjdu <br />CAC LC .s f rvtp) c o1,c t <br />( W--'A4� �' A a '4- <br />Not ry Public <br />My Commission expires: (0%,% -, /A?Q � <br />SIGNATURES MUST BE IN BLUE INK <br />RECEIVFn <br />APR 0 r 2014 <br />Division of Reclamation, <br />Mining & Safety <br />,SPRY. P... <br />2' KIMBERLYA.• -. <br />CHAVEZ ' <br />P0 �9��C` OF COL�PPO °�\ry° <br />�iSSION exP►aES �6� <br />