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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(1)(a)(VIU). <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 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 foray has been approved by the Mined Laird Reclamation Board pursuant to section 34-32.5-110,0 R.S., of the Colorado Land <br />Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of this faun shall result in voiding any <br />perinit issued on the altered or inodifred form and subject the operator to cease and desist orders and civil penalties far operating <br />without a perinit pursuant to section 34-32.S-123, CRS. <br />Signed and dated this 42LL day of <br />r <br />Applicant/Operator <br />Signed: <br />Title: P ►rL' c^t <br />State of L `� <br />Countyof � <br />The foregoing instrument was acknowledged befoi <br />by T y l C f�--� _ as <br />NICOLE KRAUTH <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />NOTARY ID 19964DI5322 <br />If Corporation Attest (Seal) <br />Signed: <br />Corporate Secretary or Equivalent <br />Town/City/County Clerk <br />My uonvntssion expires: I - I(, - — <br />MY COM&IISSIAN EXPIRES OCTOBER 6,2020 SIGNATURES MUST BE IN BLUE INK <br />'C <br />