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-7- <br />Ctrtificagon: <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 />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)(c), C.R.S.). (INCITE: For 110 operations, the affected area includes all lands delineated by the permit <br />boundary.) <br />3. No itnining 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. 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 farm has been approved by the Alined Land Reclamation Boardpursuant to section 34-32.5-110,0 R.S, ofthe Colorado Land <br />Reclamation Act for the EVraction of Construction Materials. Any alteration or rnodifieation of this form shall result In voiding any <br />permit issued on the altered or modifted 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 __ __� • day ofa�,— <br />1 <br />t <br />___�....._.w... Applicanti(,1pe or <br />f <br />Signed: <br />Title:�r siai a, <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />TovtWCity/County Clerk <br />c^ <br />County of t'Y2riW_t- <br />The foregoing instrument was acknowledged before me this 1—* _ <br />g � g �_..._. day of <br />.by n as of 'Q <br />, "Fedi 1')'1X <br />Notary is <br />My Commission expires: _ I <br />SIGNATURES MUSTBE IN BLUE INK — <br />JC3CI D. RICKER <br />NOTARY PUSLIC <br />STATE OF COLORADO <br />NOTARY 10 20M00J792 <br />lirCOWS"E»l OCT s,2*u <br />