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36 RECEIVED <br /> SEP 2 9 2014 <br /> Durango Field Office <br /> Certification: Division of Reclamation, <br /> Mining and Safety <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 /> 1. All necessary approvals from local government have been applied for(Section 34-32.5-110(l)(a)(Vllt). <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. 1 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 I 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 3432.5-110,C.R.S.,of the Colorado Land <br /> Reclamation Act for the Extraction of Construction Materials Any alteration or modification of thisform 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 far operating <br /> without a permit pursuant to section 34-32.5-123,C R.S <br /> Signed and dated this A day of <br /> l4elle 4W © (f (/ if Corporation Attest(Seal) <br /> Applicant/Operator / <br /> /gned: Signed: <br /> Corporate Secretary or Equivalent <br /> ing Partner <br /> Town/City/County Clerk <br /> State of 0,(0 rad.0 ) <br /> � <br /> County of k_0 1 j��af,(Zl )ss.) <br /> The foregoing instrument was acknowledged before me this day of 1! ' ZO/ , <br /> by Jodi n t1 as of <br /> OR@®ORY WILLIAM FREITAG N blic <br /> NOTARY PUBLIC <br /> STATE OF COLORADO My Co mmi ion expires: ZU/ <br /> NOTARY ID 20144023772 <br /> MY COMMISSION EXPIRES JUNE 13,2018 <br /> SIGNATURES MUST BE IN BLUE INK <br />