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722163 11/12/2014 12:45 PM 8: 01010 P: 336 DOCUMENT <br />Page: 1 of S R $0.00 D $0.00 T $0.00 <br />Pamela M. Bacon Clerk & Recorder, Logan County, Co <br />mill Kfur H VIONW1 ,1M 11WAR11' ARVI 111 VA411111 <br />-8- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum <br />requirements of the following terms and conditions: <br />1. To the best of my knowledge, all significant, valuable and permanent man-made structure(s) inexistence at the time <br />this 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.). <br />2. No mining operation will be located on lands where such operations are prohibited by law <br />(Section 34- 32.5- 115(4)(f), C.R.S.; <br />3. As the applicant/operator, I do not have any extraction/exploration operations in the State of Colorado currently in <br />violation of the provisions of the Colorado Land Reclamation Act for the Extraction of Construction Materials <br />(Section 34- 32.5 -120, C.R.S.) as determined through a Board finding. <br />4. I understand that statements in the application are being made under penalty of perjury and that false statements <br />made herein are punishable as a Class 1 misdemeanor pursuant to Section 18 -8 -503, C.R.S. <br />This form has been approved by the Mined Land Reclamation Board pursuant to section 34- 32.5- 112,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 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 />Signed and dated this & H I day of / V c7 V P I I 1 Z) I t <br />o 00 (mot, 0 tv If Corporation Attest (Seal) <br />Applicand6perator or Company &ame <br />Signed: <br />Title: 0 P (2.,Ca,JJ 0 0 S <br />i <br />State of Lo 10 ca _j 0 ) <br />County of Lod a 0 ) <br />Si ed: <br />Corp pleat Searet�ry or Equivalent <br />.,�, <br />Pun <br />P � i <br />T�h�e� foregoing instrument was acknowledged before me this day of � <br />0! O�G� �� tr i �1 <br />as S <br />-,by & VA&Cj42 of JJ�zu <br />GtiRS <br />a Q: Qy • • OP Notary Public �— <br />vz Z v : o z My Commission expires: <br />%mod: ��' U•`. <br />4 <br />SIA Y'i1AES n1` IN BLUE INK <br />You must post sufficient Notices at the locatiorit /cYFrtlta�_0 posed mine site to clearly identify the site as the location of a <br />