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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 ofthe <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 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. 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 Mined Land Reclamation Board pursuant to section 34-32.5-110,C.R.S.,of the Colorado Land <br /> Reclamation Act for the Extraction of Construction Materials. Any alteration or modification of thisform shall result in voiding any <br /> permit issued on the altered or modifred 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 /> 4 <br /> Signed and dated this day of <br /> Jr <br /> If Corporation Attest(Seal) <br /> pp icant/Operator <br /> Signed: -✓�� `� Signed: <br /> / Corporate Secretary or Equivalent <br /> Title: ��S /¢CZ i N Town/City/County Clerk <br /> r <br /> State of oJ`O C'r—t ) <br /> ss. <br /> County of <br /> r� <br /> The rego1ing instrum nt was acknowledged before me this -1 day of , <br /> by i c kC as Q �[L &—!t, of <br /> Notary Pu lic <br /> My Commission expires: %0 -2, <br /> SIGNATURES MUST BE IN BLUE INK 4a#&2.Masq" <br /> NOTARY PUBLIC <br /> STATE OF COLORADO <br /> NOTARY ID 19964012722 <br /> My Commission Ex Tres August 10,2020 <br />