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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 terns and conditions: <br />1. All necessary approvals from local government have been applied for (Section 34-32.5-110(1)(aXVIII). <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 beep identified in this application <br />(Section 34-32.5-115(4Xe), C.R.S.). (NOTE: For 110 operations, the affected area includes 1 lands delineated by the pennit <br />boundary.) <br />3. No milling operation will be located on lands where such operations are prohibited by law (Section 34-325-1 15(4Xt), <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 andthat 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 34-32.5-140,C.R.S., ofthe Colorado Land <br />Reclamation Act for the ExiractionofConstruction Materials. Any alteration ornwd4fication ofth4form shall result in voiding any <br />permit issued on the altered or modified form and subject the operator to cease and desist orders find civil penalties for operating <br />without a permit pursuant to section 34-32.5-123, C.R.S. <br />Signed and dated this 30th <br />Daniel L. Collins <br />day of December <br />Applicant/Operator <br />Signed: <br />Title: Managing Partner <br />State of Colorado <br />County of San Miguel <br />) ss. <br />The foregoing instrument was acknowledged before me this <br />by <br />as .. <br />DASARO <br />IDT/AY PUBLIC <br />to"). a J`.= CO'...ORADO <br />r <«R4 ID 2C 4:003856 <br />!i +�: ;`.:'.�3 :1r EVCRES02/14/2017 <br />If Corporation Attest (Seal) <br />Signed: .k <br />Corporat= Secretary or Equivalent <br />Town/City/County Clerk <br />day of <br />oft: <br />/? 1 <br />Notary Public <br />My Commission expires: <br />SIGNATURES MUST BE IN BLUE INK <br />