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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 /> 1. All necessary approvals from local government have been applied for(Section 34-32.5-110(lxa)(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 34-325-115(4)(e),CILS.). (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 34-325-115(4)(f), <br /> C.R.S.). - - - --- <br /> 4. As the applicantloperator,I do not have any mininglexploration operations in the State of Colorado currently in violation of <br /> the provisions of the Colorado Land Reclamation Act for the Extraction ofConstruction 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 nude herein <br /> are punishable as a Class 1 misdemeanor pursuant to Section 18-8-503,C.R.S.1984. <br /> Thisform has been approved by the Mined Land Redamaden Board pursuant to section 34-325-110,CRS,ofthe Colorado Land <br /> Reclamation Actfor the F n ofConstrudion Materials Any alteration orrnodfuaton ofifth formshalf mw&In voiding any <br /> pernat issued on the altered or nwdbW form and subject the operator to cease and desist orders and evil penalties for operating <br /> without a pernat pursuant to section 34-325-123,CR.S // <br /> Signed and dated this day of o( h Y r Z6 <br /> 00 <br /> 4 ; <br /> If Corporation Attest(Seal) <br /> Applicant/Operator - r <br /> Signed: _� L---� :�G�t:�4( � Signed: <br /> rj <br /> Title: T*�Gounty Clerk <br /> State of <br /> )ss. <br /> County of ik5h!Vial InIq <br /> The foregoing instrument was acknowledged before me this ��� day of <br /> by --•f ? L7. Zel, ' of <br /> NOTARY PUBLIC <br /> STATE OF COLORADO -Notary Public <br /> NOTARY ID 19954016062 V. <br /> MY COMMISSION EXPIRES 121Q61201 fro i My Commission expires: <br /> SIGNATURES MUST BE IN BLUE INK <br /> 1 <br />