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-7- <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 34-32.5-1. 10(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 3432.5-115(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 tate Colorado Land Reclamation Act for the Extraction of Construction Materials (Section 34-32.5-120, C.R.S.). <br />S. 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 forst has been approved by the Mined Lard Reclamation Board pursuant to section 34-32.5-110,C.RK, of the Colorado Land <br />Rech madon Act for the F.xtracdon of Construction Materials. Any alteratio a or modifrcadon ofthis form shall result in voiding any <br />pe mit issued on the ahered 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. I <br />1 11 <br />Signed and dated this day of Z'.C.FU'/(i- 1 t <br />6 <br />L Gkh <br />Appli erato <br />Signed: / <br />Title: I <br />If Corporation Attest (Seal) <br />Signed: + <br />orporate Secretary or Equivalent <br />Town/City/County Clerk <br />State of 1/l_ <br />County of <br />The foregoing instrument was acknowledged before me this (' 11 day of <br />by �D� Vk a,.N 1 ��1 Tt as �rC7iAti✓I r of e <br />c. <br />SHMELL CARTER434SEN <br />Ndwy Pthlc f <br />gA6011A8h My Commission expires: rt q2 L" <br />Mp Oantiefion Et�kea 1115 <br />...COMMNSS10N NO. 613431 <br />SIGNATURES MUST BE IN BLUE INK <br />