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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 /> I. All necessary approvals from local government have been applied for(Section 34-32.5-110(1)(a)(VIB). <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 Mined LandReclamation Boardpursuant to section 34-32.5-110,C.R.S.,of the Colorado Land <br /> Reclamation Act 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.R.S. <br /> Signed and dated this •Z 7 day of �ar , o{ 6 <br /> �-V"- C\ S If Corporation Attest(Seal) <br /> Applicant/Operator <br /> Signed: ;Z' ___r-- - Signed: <br /> -+ Corporate$Nretary or Equivalent <br /> Title:Q`e s t d�.�T Town/Ci un Clet{. <br /> State of <br /> ss. <br /> County of <br /> The foregoing instrument was acknowledged before me this "j day of <br /> ,by as of 'C, . <br /> L M LOUISE., mvror)EAU Notary Public <br /> NWAW P iJbUC <br /> STATE OF COLORADO My Commission expires: <br /> NOTARY ID 20144020416 <br /> MY OObt11 MION EXPIRES MAY 20,2018 <br /> incTivrmMs MUST BE IN BLUE INK <br />