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FEB 2 7 2012 <br />QVM JiiNCU,* HELD OFFl-E <br />Certification: I faMAT� WMWG & SAFM <br />As an authorized representative of the applicant,) hereby ccrtify that the operation described has met the minimum requirements of the <br />following terms and conditions. <br />All necessary approvals from local government have been applied for (Section 34-32.5-110(l)(a)(V111). <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)(#), <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 1 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-I10,C.) S , of the Colorado Land <br />Reclamation Art 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. S. <br />Signed and dated this day of <br />i <br />,T /%/0�rt�t✓ e,k S Alli /�,t � j2iiUt �- 1f Corporation Attest (Seal) <br />Applicant/Operator <br />Signed: _I�%__. Signed: <br />r <br />Corporate Secretary or Equivalent <br />Title: 67 trlMe g Town/City/County Clerk <br />Stateof <br />) ss. <br />County of _" ) <br />3§'1`, L <br />The foregoing instrument was acknowledged before me this �, day of ^�/a <br />by �� �,v) as _ ( v� t P " of"t`.�s `.X, C <br />ublic <br />My Commission expires: <br />SIGNATURES MUST BE IN BLUE INK <br />5r <br />r <br />s <br />• <br />Y r <br />• r <br />Y r <br />K 0 <br />