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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 /> I. 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 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 appticanVoperator,I do not have any minintexploration 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. 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 I misdemeanor pursuant to Section 18-8-503,C.R-S. 1984. <br /> This form has been approved by the Alined Land Reclamation Board pursuant to section 34-32.5-110,C_1L&,of the Colorado Land <br /> Reclamation Act for the Extraction of Construction:Materials. Any alteration or modification ofthis form shall resuh in vooiding 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. <br /> 7pu <br /> and dated th' day of <br /> �� G"("�/�//J �� if Corporation Attest(Seal) <br /> Ape can rat <br /> Signed: ` �`" - Signed: <br /> / Corporate Secretary or Equivalent <br /> Title: lc rt t Town/City/County Clerk <br /> State of C", reU ) <br /> )ss. <br /> County of The foregoing instrument was acknowledged before me this U � day of i y <br /> Y 1 , <br /> ,by d�� ��k� (1)rz as of r /4 alJO(t�YS <br /> ANNE DUSTIN <br /> NOTARY PUBLIC ?Notary Public <br /> STATE OF COLORADO <br /> NOTARY ID#20044009724 My Commission expires: O l 2-()2- <br /> MY Commission Expires March 18,2020 <br /> SIGNATURES UST BE IN BLUE INK <br />