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-6- <br /> Certification: <br /> As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum <br /> requirements of the 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 <br /> this 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 <br /> permit boundary.) <br /> 3. No mining operation will be located on lands where such operations are prohibited by law (Section <br /> 34-32.5-115(4)(f),C.R.S.). <br /> 4. As the applicant,operator,I do not have any mining,'exploration operations in the State of Colorado currently in <br /> violation of the provisions of the Colorado Land Reclamation Act for the Extraction of Construction Materials <br /> (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 <br /> made herein 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,C.R.S., of the <br /> Colorado Land Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of this form <br /> shall result in voiding any permit issued on the altered or modif ed form and subject the operator to cease and desist orders <br /> and civil penalties for operating without a permit pursuant to section 34-32-123, C.R.S. <br /> Signed and dated this 4q+h day of May , 2005 <br /> Cheyenne County If Corporation Attest(Seal) <br /> Applicant/Operator <br /> Signed: Signed: ^ �� <br /> Title: County Administra.t;or `T-a�' �County Clerk <br /> State of Colorado ) <br /> )ss. <br /> County of Cheyenne _ _) <br /> The foregoing 'instrument was acknowledged before me this day of l <br /> by_ t' as of <br /> �J,6 <br /> ` Nota Public <br /> ;My Commission expires: <br /> SIGNATI,JRES-MUST"BEIN SLUE INK <br />