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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 />All necessary approvals from local government have been applied for (Section 34-32.5-110(I)(a)(Vlll). <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 applicantloperator, I do not have any mining/exploration operations in the Slate 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. 1 understand that statements in the application are being made under penalty ofpedury and that false statements made herein <br />are punishable as a Class I misdemeanor pursuant to Section 18-8-503, C.R.S. 1984. <br />Tltis form has been approved by the Mined Land Reclaneation Board pursuant to section 34 32.5-110,0 R.S, of the Colorado Land <br />Reclamation Actfor the Ertraction of Construction Materials Any alteration or modification of thisform shall result in voiding any <br />permit issued on the altered or modifed form and subject the operator to cease and desist orders and civil penalties jar operating <br />without a permit pursuant to section 34-32.5-123, C R.S <br />Signed and dated this <br />loth <br />Cheyenne County <br />Applicant/Operator <br />Signed: <br />Title: Chairman <br />day of January 2017 <br />State of Colorado ) <br />ss. <br />County of Cheyenne <br />The foregoing instrument was acknowledged before me this <br />by Rod Pelton as <br />10th <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City;'Count ' Cler' <br />day of January, 2017 <br />Chairman A of ie enne Coun <br />S <br />814ot*ublic <br />My Commission expires: t <br />SIGNATURES MUST BE IN BLUE INK <br />