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-7- <br />Certification: <br />As an authorized representative of the applicant, I hereby cdify that the operation described has net 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 permit <br />boundary.) <br />3. No mining operation will be located on Iands 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 f) <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 staterrents in the application are being nade under penalty of per)ury and that false staterents 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 limed Land Reclamation Board pursuant to section 34- 32.5- 110,C.R.S, of the Colorado land <br />Reclamation Act for the Extraction of Construction Materials. Ap alteration or modification of this form shall result in voidrg 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.R.S. <br />day of Mal �s� � 7 nN <br />Signed and dated this y c,3i` •- •-�; <br />- +c!fA A <br />Lun;6 EDair171 1 �1 D1ilZ�CJ If Corporation Attest (Seal :, ♦ �, <br />Applicant/Operator <br />J �� r �� • <br />Title: &a i'Y rmn <br />Signed <br />Corpor a Secretary or Equivalent <br />Town/City /County Clerk <br />State of <br />ss. <br />County of <br />The foregoing instrument was acknowledged before me this '� day <br />by N hhi as of , <br />VIdX3 1SSiWWO3 Z al kSVILON otary ub is o do 31tt1S <br />1IMLON y Commission expires: <br />3ii3NNV <br />SIGNATURES MUST BE IN BLUE INK <br />/6/11 <br />&I <br />