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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(4xe), 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.RS. 1984. <br />This form has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5- 110,C.IL&, of the Colorado Land <br />Reclamation Adfor the Extract ionofConstrucdonMaterials. Any alteration or modificationoftiiisform shag resullinvoidingany <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, CRS. <br />Signed and dated this T day of _ t �' VsK c1 k 20 t <br />Title: �� PwT ,%A"A 2 <br />Ir <br />State of ��Ga(,G*9 ctCf6 1 <br />�� "" ) ss. <br />County of _�6 tt t'O m <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City /County Clerk <br />The foregoing instrument was acknowledged before me this 14 k- day of -??'?.IA 8.4 <br />,by &rod b-i ,e [ as /�i aL i?a'Aca "A of �G uri c <br />Notary Vublic V <br />d <br />My Commission expires: <br />SIGNATURES MUST BE IN BLUE INK <br />