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-7- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met them inimum 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)(VI11). <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(4ye), 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 ofthe Colorado Land Reclamation Act forthe 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 />This form has been approved by the Mined 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. 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 for operating <br />without a permit pursuant to section 34 -32.5 -123, C.R.S. <br />Signed and dated this q (� day of 2&',kAjZi `;�a )s <br />A / <br />Apptiicant/Operator <br />Signed• <br />Title: Mayor <br />State of <br />) ss. <br />County of ) <br />The forkgoing instrunTVt was acknowledged before me this <br />by die, �tkr. W as Ab <br />CIT <br />If Corporation Attest (Seal) <br />Signed`` 4-" �(,P. <br />Corpor e Secretary or Equwalal <br />ent <br />day of <br />Notary Public <br />Town/City/County Clerk <br />q ('5- <br />My Commission expires: <br />SIGNATURES MUST BE IN BLUE INK <br />TILUE M FISBECK <br />ROTARY PUBLIC <br />STATE OF COLORADO <br />NCTFARY ID 18844017529 <br />P;1Y COM1• !SVON UPIRES OCTOBER 26, 2014 <br />