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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 /> 1. 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)(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 ofpedury and that false statements made herein <br /> are punishable as a Class 1 misdemeanor pursuant to Section I8-8-503,C.R.S. 1984. <br /> This form has been approved by the Mined Land Reclamation Board pursuant to section 34-32.5-110,C.R S.,of the Colorado Land <br /> RedwnalkmAct for the Extraction of Construction Materials.Any alteration or modification ofthisform shall resuit 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,GRS. <br /> Signed and dated this aq day of AuS�-- 2011 <br /> Harry Corkle Const If Corporation Attest(Seal) <br /> Applicant/Operator <br /> Signed: Signed: <br /> Corporate Secretary or Equivalent <br /> Title: President Town/City/County Clerk <br /> State of Colorado ) <br /> County of Jackson s nn 1 <br /> The foregoing instrument was acknowledged before me this day of 17 U 4 U s ! <br /> by Harry Corkle as President of Harry Corkle Const <br /> �o-oevv�o<--moo ��t.GL L��a�iYLJL_ <br /> DEBRA L. GREENE Notary Public <br /> NOTARY PUBLIC My Commission expires: <br /> STATE OF COLORADO <br /> My Commission Exuires 06/23/2WNATURES MUST BE IN BLUE INK <br />