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-7 - <br />Certification: <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(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 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. I 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 1 misdemeanor pursuant to Section 18-8-503, C.R.S. 1984. <br />This form has been approved by the MinedLand Reclamation Boardpursuant to section 34-32. S-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 129" day of J yn e , 2101 s , <br />l -!C V12 es 14 <br />Applicant/Operator <br />Signed: i <br />Title: <br />1-4 cl'� / 0 a iii er - <br />State ofd ) <br />� <br />J ) ss. <br />County of 1 '` I * 7�'V se ) <br />The foregoing instrument was acknowledged before me this <br />,by --7_;dd D 1kVAt' as <br />Teresa C. Kemp <br />State of Colorado <br />Notary Public <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />,20�\ <br />day of 1)(1< <br />t")l c> of JRr <br />Notary Public / r/ <br />My Commission expires: <br />SIGNATURES MUST BE IN BLUE INK <br />