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-6- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum requirements of <br />the following terms and conditions: <br />All necessary approvals from local government have been applied for (Section 34-32.5-111(1)(a)(IX)); <br />This entire mining operation will not affect more than 30 acres; <br />3. This mining operation will not adversely affect the stability of any significant, valuable and permanent man-made <br />structure(s) located within two hundred (200) feet of the affected lands. (However, where there is an agreement between <br />the applicant/operator and the persons having an interest in the structure that damage to the structure is to be compensated <br />for by the applicant/operator (Section 34-32.5-115(4)(e), C.R.S. 1984, as amended), then mining may occur within 200 feet. <br />Proof of an agreement must be submitted to the Office prior to the decision date.) <br />4. 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. 1984, as amended); <br />5. As the applicantloperator, I do not have any mining/exploration operations in this 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. 1984, as amended) as determined through a Board finding. <br />6. 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. 1984, as amended. <br />Thu form has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-111,CR.S., of the Colorado <br />Land Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of thisforin shall result in <br />voiding any permit issued on the altered or modified form and subject the operator to cease and desist orders and civil penalties <br />for operating without a permit pursuant to section 34-32.5-123, C.R.S. <br />Signed and dated this _�_ day of <br />Lazy H Inc <br />Applicant/Operator <br />By: <br />Title: William K. Havengar, Owner <br />State of CADV-OAC } <br />) ss. <br />County of 115,0 ) <br />If Corporation Attest (Seal) <br />R) s� <br />By: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />The foregoing instrument was acknowledged before me this _ 6 day of -r"r 4n i i zr) 1 5 <br />by Ot,A conn 1 j -0Y -\g a I-- as I()( P_> r )ojr of /,Q Z'L <br />Susan K Khrmn <br />Notary Public <br />State Of Colorado Notary Public <br />Notary ID 20044041221 � <br />Withl"IM ROOM ftntriber 24,20 <br />�- My Commission expires: 44-"x/ �{ <br />SIGNATURES MUST BE IN BLUE INK <br />