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Certif ication <br />As an authorrrcd representative of the applicant, I liewb} certify that the operation described Iuas met the nmunnan ictpuucmcnt.0f the <br />folltm ing ternis and condiuons. <br />All necessary approvals from local governmem }ray e been applied for (Section 34-32,5-110(11 a x Vlll ) <br />2 'I o the hest of my knoxiledge. all significant. valuable and permanent man -made structure(s) in c cistence al the titnc phi: <br />application is hied. and located within 200 feet of the proposed affected area have been identified in this; application <br />oSktition 3.1 -32 5 -1 1i(4) cr. C.I2.S }, iN{ IT: For i to operations the afieetedarca ineludes all lands delineated INv tlx: pennn <br />boundan ) <br />3. No mining, operation gill be located on lands where such operations are prohibited hY taw (Section 34-12 5 -I 150 K0, <br />(,'.12 S.) <br />i As the appheantloperator. I do not have any inimnglexplorttuon operations in dm State. of Colorado cturcntl) in violation of <br />the pro\ istons of the Colorado land Reclamation Act for the bixtraetton of Construction Material. (Section 3 -b -32 ; -12t1. C 1Z.S ) <br />1 understand tluat statement, nt the application are hang made ender penalty (if periury and that title statement, made herein <br />nre punrsluible as a Class I nusdemcanor puzstumt to Section 19 -9 -501. C it S 1984 <br />This, form hav been approved by the Afined Land Reclamation Board pursuant to section 3d- 32.3 -11 ©,C :R.S., ofthe Colorado Land <br />Recidirmadon .get for the Extraction aj'Ccmctnuflon Materialc..An), alleratiatt or modiftccttiott ofthis form shall resatll in voidi»g amt' <br />permit icsrted tut rite altered or modified form and .subject the operator to cease and desist orders and civil pettalWev for operating <br />without a permit pimnant to ved on 34 -32.3 -123, C:R.S. <br />Signed anti (l;A this _ ..._____ d<n of t Lt zo-4 <br />11tle. <br />State of C-0 10p— u�o r <br />if Corlx> ration Attest (Seal) <br />Signed <br />Corliotak: Sccictar�, or l'.yuivalent <br />I oxmi aid 1Courti Clerk <br />1 lie tiircroing in:trunlcrrt was ackno%A (edged heli,rc tut tin �� day of e3 ee C, <br />t,ti t�-r _ _ _ f -_ __ _ ____ _ a, _ 1 r _Yi - -- - -- - -- - -- - of d . , . f ttt"M^1 S <br />� tf view o-r-ty <br />- <br />;tint iN Public I u � <br />its+ Cnnuirtisxm e�pires _ C�� <br />SIGNATURES &1U,'ST BE IN BLUE INK <br />APR <br />Division of Recia- oration, <br />Mining & safety <br />PM <br />