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-a- <br /> Certification: <br /> As an authorized representative of the applicant,I hereby certify that the operation described has met the minimum requirements ofthe <br /> following terms and conditions: <br /> l. 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 he 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/explomtion operations in the State of Colorado currently in violation of <br /> the provisions of the Colorado Land Reclamation Act forthe 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 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 Land Reclamation Board pursuant to section 34-32.5-110,CJZS.,of the Colorado Land <br /> Reclamation Act for the Extraction of Construction Materials. Any alteration or modicadon 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 J, day of c 10 12 <br /> If Corporation Attest(Seal) <br /> Applicant perator <br /> Signe k` Signed: <br /> Corporate Secretary or Equivalent <br /> Title: Manager <br /> Town/City/County Clerk <br /> State of rL;I C ng clo ) <br /> ss. <br /> County of C�('1 j�l ) <br /> The foregoing instrument was acknowledged before me this day of lA�Ll r f <br /> by 7 t < as M Ct 1'1 A CA(�Y of �kk P I I e U �wi� ` 4ei f�,L-!'; <br /> BRENDAKLECFIAIMI &otary <br /> NOTAMy Ideftftdon RY PUBLIC-STATE OF COLORADON Public y #rj 20 My Commission expires: d.l(i tC_71 <br /> E9W <br /> SIGNATURES MUST BE IN BLUE INK <br />